AHA's Rural Podcast Series

Community Cornerstones: Conversations with Rural Hospitals in America

Rural hospitals in the United States are struggling to maintain obstetric services, and in the last five years more than 300 birthing units across the country have shut down. San Luis Valley Hospital is fighting this trend, implementing creative strategies to keep obstetric services open for their communities. In this conversation, San Luis Valley Hospital's Monica Hinds, R.N., director of emergency services and obstetrics, and Stephanie Posorske, certified nurse midwife, discuss their approach to cross-training units with minimal resources, and partnering with community stakeholders to keep the lights on for new and future families.


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00:00:00:13 - 00:00:24:07
Tom Haederle
Changing demographics and financial pressures pose challenges for hospitals, especially those in rural communities, to maintain obstetric services. In the last five years, more than 300 birthing units across the country have shut down.

00:00:24:09 - 00:01:06:18
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Despite today's many challenges, some hospitals are implementing creative strategies to maintain necessary obstetric services for their communities. San Luis Valley Hospital in rural central Colorado is cross-training its clinical staff and partnering with community stakeholders to keep serving their community. Julia Resnick, AHA's director of Strategic Initiatives, recently spoke with Monica Hinds, an RN and director of Emergency Services and Obstetrics and Stephanie Posorske, a certified nurse midwife, about their approach to maternal care for the San Luis Valley community.

00:01:06:20 - 00:01:15:02
Julia Resnick
So, Monica, Stephanie, thank you both so much for joining me. Let's start with some background about each of you and San Luis Valley Health. Monica, I'll start with you.

00:01:15:04 - 00:01:40:14
Monica Hinds, R.N.
I am new to nursing. I've been a nurse for about ten years. This is my second career. and I attribute my nursing drive to OB, actually. When I had my kids, the OB nurses here at San Luis Valley Health were awesome, and I felt like that's what I wanted to give back to the community. So that was a little bit about myself.

00:01:40:16 - 00:01:58:11
Monica Hinds, R.N.
I have been overseeing the OB department for the last 4 to 5 years, I think is when I took over. I was, originally, an emergency room nurse. Became director of the emergency department, and then just sort of, fell into the OB leadership position as well.

00:01:58:14 - 00:02:03:02
Julia Resnick
So can you tell me a just a little bit about the community that is in the Valley?

00:02:03:04 - 00:02:22:28
Monica Hinds, R.N.
Alamosa is the central hub of the Valley. We do service several communities throughout the area, the San Luis Valley. And we are the only location that does labor and delivery. And so everyone does come to us, or they go outside of the valley for their OB needs.

00:02:23:05 - 00:02:26:21
Julia Resnick
Got it. And what kind of pregnancy care does your hospital provide?

00:02:26:23 - 00:02:44:24
Monica Hinds, R.N.
We pretty much do everything. Because even if we cannot manage the patients here, we make sure that we get them to that higher level of care. So we do have the C-sections, we do induce, we do have a local midwife that does deliver outside that we do support as well for her needs.

00:02:44:27 - 00:02:52:06
Julia Resnick
And tell me a little bit about the community stakeholders and partners that you work with, both for prenatal care and postpartum care.

00:02:52:08 - 00:03:11:07
Monica Hinds, R.N.
So we do have valley wide. They are also part of our labor and delivery department. They do manage their own patients. Do their own deliveries, do their postpartum care as well. And then we do have our ObGyn clinic here that, manages our patients for our hospital.

00:03:11:10 - 00:03:24:28
Julia Resnick
So turning to you, Stephanie. I know that there are a lot of challenges faced by rural communities, especially in terms of maternal care. So can you talk about some of the challenges, that expectant and postpartum moms are facing in your community?

00:03:25:00 - 00:03:49:18
Stephanie Posorske
So, interestingly enough, I think that social media has changed this significantly in the last ten years in the sense that everybody knows what's out there, and then what's that availability here? So they're, you know, they want to know, like, can I have an epidural? And yes, they totally can. And being able to meet those needs.

00:03:49:18 - 00:04:19:25
Stephanie Posorske
I think that we do a really good job of finding the niches that are really important. For example, women really worry about being able to have a lactation consultation. And while we don't have a specific lactation counselor, that that's just what they do. I'm our hospital's lactation counselor, on top of being a certified nurse midwife, so that we can still meet those needs without, you know, having to expend our resources.

00:04:19:27 - 00:04:41:08
Julia Resnick
Got it. And, you know, every day we're hearing about more OB units closing down unlimited access in rural communities. But you all are some of the rare ones who are managing to keep yours up and running and serving your community. So can you tell me about what strategies you're implementing that's able to keep your maternity unit open and thriving?

00:04:41:11 - 00:05:05:18
Monica Hinds, R.N.
We are seeing a decrease in, deliveries per year as well. And to be able to make our department managable as far as financial, we've really had to think outside of the box on what we're going to put on that unit. So we have expanded our unit to that surge overflow unit. We have implemented pediatric patients on part of our unit.

00:05:05:21 - 00:05:26:00
Monica Hinds, R.N.
We do some post-surgicals that are not Ob-Gyn related on our unit. So we really have grown our OB nurses into well-rounded nurses that do everything. And so we give them a lot of credit for the knowledge that they've had to obtain over these last few years just to be able to care for our patients in our community.

00:05:26:03 - 00:05:29:02
Julia Resnick
That's really wonderful. Stephanie, anything else you want to add?

00:05:29:04 - 00:05:57:03
Stephanie Posorske
Yeah, I think that there has come a lot of flexibility and changing our expectations of what works for people, and that that's what like all these units that have been able to stay open have had to do...is that we've had to become more flexible as an employee, but also the employer has had to become more flexible on what meeting the needs of everybody's situation so that we can keep this resource available.

00:05:57:05 - 00:06:17:14
Julia Resnick
That's great and wonderful that you're all willing to be so adaptable as you're trying to make your way through this. So besides clinical services, we know that a lot of rural women are also experiencing challenges around behavioral health, such as substance use, and other issues related to social determinants of health. So how are you addressing those issues in your community

00:06:17:16 - 00:06:20:29
Julia Resnick
especially for pregnant and postpartum women?

00:06:21:01 - 00:06:44:19
Stephanie Posorske
I think I can answer that. So I prescribe Suboxone, which is for people that use opiates. And on top of that, like being a great resource for people that use opiates so that they can hopefully get off opiates, it also opens the door for all avenues of people knowing that we're open to doing that and what we can do to help.

00:06:44:21 - 00:07:08:00
Stephanie Posorske
I think we really want to get out there this idea of like, we want you to come in, we want you to get care. Despite all of these challenges, whether it's for behavioral health or because you use some substance, we want to be the doors are open because this is an opportunity for us to capture people that are using

00:07:08:03 - 00:07:20:18
Stephanie Posorske
and it's when they're going to be most motivated to make a change in their lives. And so keeping that door wide open is the best way to do that and hopefully is working.

00:07:20:21 - 00:07:22:17
Julia Resnick
Monica, anything you want to add?

00:07:22:19 - 00:07:48:27
Monica Hinds, R.N.
So I would really like to add we do depression screening on all of our patients - no matter if they're observation patients or inpatients, postpartum in the middle of their pregnancy - just so we can try to catch these patients early enough to be able to give them the resources that they need. We have also really focused on our social determinants and making sure that we're asking those hard questions of patients, you know, do they need some help with housing?

00:07:48:27 - 00:08:06:16
Monica Hinds, R.N.
Do they need transportation? Is food a difficulty for them at this point in time? And we have great care coordination that actually will follow up on all of those patients prior to them being discharged to make sure that they're providing them the resources in the community that they need.

00:08:06:18 - 00:08:29:09
Julia Resnick
And yeah, I think you're both really getting at this idea that, like, these are sensitive questions and sensitive topics for people and keeping that door open so that they feel comfortable coming to you and asking for the support they need is just so crucial. So we always love stories that can really bring this to life. Do you have any stories from your hospital or patient stories, that can help bring to life the work you're doing?

00:08:29:12 - 00:09:02:03
Stephanie Posorske
I have a patient. She's had a baby already. Her and her partner have had times where they've used either fentanyl or opiates. And that door has stayed open to them, despite their not always being as compliant as we would like them to be. But they continue to come see us. Another provider in my clinic sees her husband so that we are both taking care of both of them and their substance use.

00:09:02:05 - 00:09:25:18
Stephanie Posorske
It's just lovely for them, like to have their baby, and for us to be continuing to work on this medical problem that they have. And it's not black and white and it's not it's not super easy. But every time they bring that little baby in and that they're still together and that they're still coming is exactly why that that door has to stay open.

00:09:25:21 - 00:09:34:08
Julia Resnick
Absolutely. And clearly the motivation is there. Yeah. And it's wonderful that you embrace them. Monica, any stories from your world?

00:09:34:10 - 00:09:58:00
Monica Hinds, R.N.
I don't have any specific patients. I mean, we do see when those those patients come in that have that substance use and and we're able to, you know, get them the resources that they need and be able to get them reunited with their baby, even if they aren't able to leave with them at discharge. But to be able to help them get that custody back.

00:09:58:02 - 00:10:06:07
Monica Hinds, R.N.
We see it, you know, not daily, but we see it a lot. It warms our heart that we can help those patients get back with their babies.

00:10:06:09 - 00:10:17:15
Julia Resnick
That is wonderful. So for other rural hospitals that are considering different creative avenues for providing maternal care, what advice do you have for them? What have you learned along the way?

00:10:17:17 - 00:10:56:10
Monica Hinds, R.N.
I'm going to say that you have to listen to your staff. It's been very difficult making that transition from just being a labor and delivery nurse and moving into other fields. It's definitely a lot easier with the newer nurses that are coming out, because that has expectations set forth on employment. But for those those experienced labor and delivery nurses, taking that time to listen to them, about their concerns and what kind of education that they need to make sure that they feel comfortable in providing the care to patients that they haven't cared for, you know, since nursing school, probably.

00:10:56:12 - 00:11:05:03
Monica Hinds, R.N.
So just stopping and listening to concerns is something that I feel that we can really learn throughout this transition.

00:11:05:05 - 00:11:05:27
Julia Resnick
Stephanie?

00:11:06:00 - 00:11:25:09
Stephanie Posorske
I mean I think that's really important. And like listening to your staff is how we will make changes together and not be like get all that pushback. And just like the adaptability like we talked about, we have to all be adaptable. We had to be adaptable in the sense that we brought these patients to our unit,

00:11:25:12 - 00:11:46:09
Stephanie Posorske
that we sometimes have some med surge patients on our unit. But depending on what's going on on labor and delivery, we have to be able to change that. And I think all of our expectations have changed, and we've all learned to evolve with the situation. And that's the true heart of nursing and medicine is that we have to be able to evolve and change based on the patient.

00:11:46:09 - 00:11:54:15
Stephanie Posorske
But big picture: How we evolve and have adapted and changed for our unit as a whole has been really how this has worked.

00:11:54:18 - 00:12:09:22
Julia Resnick
That is an incredibly powerful message that I think we all need to to take in to the work that we do, that, you know, the world changes and we need to change along with it to make things work. So to wrap up, what's next for you all? And SLVH's is work in maternal health?

00:12:09:25 - 00:12:12:06
Monica Hinds, R.N.
I'll let you go first, Stephanie.

00:12:12:09 - 00:12:35:18
Stephanie Posorske
Well, you know, I mean, Monica knows that I always have all kinds of ideas and some of them work and some of them don't. But we, you know, we all move forward and with our ideas and, you know, like, I'd like it if we had nitrous is an option for our patients. And I think we're totally on the brink of getting that. We want to meet to the need of everybody

00:12:35:21 - 00:12:53:28
Stephanie Posorske
which is a wide variety of people really here. And so finding ways that keep us safe and financially feasible, but also our meetings and needs and make us also feel like maybe we aren't as Podunk as sometimes we think, even.

00:12:54:00 - 00:13:10:08
Monica Hinds, R.N.
Yeah. And I would definitely agree with what Stephanie is saying. We we do try to stay up with the times, but making sure that we are providing that safe environment for our patients and for our staff as well, and giving them those opportunities to continue to learn and grow in the field.

00:13:10:10 - 00:13:27:00
Julia Resnick
Well, it's clear how dedicated you all are to your patients and your community and really making sure that door stays open to them. So I just want to thank you for the great work that you're doing to to support moms in your community and really appreciate your taking the time to talk with us today about your work.

00:13:27:01 - 00:13:28:15
Julia Resnick
Thank you so much.

00:13:28:17 - 00:13:29:24
Stephanie Posorske
Thank you for having us.

00:13:29:26 - 00:13:31:28
Monica Hinds, R.N.
Yeah, thank you for sure.

00:13:32:01 - 00:13:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

Welcome to “Rural,” a yearlong series devoted to rural hospitals and health systems in America, recorded at this year’s AHA Rural Health Care Leadership Conference. Being a new parent is challenging in the best of circumstances, but it is even harder for expecting and new moms struggling with social and behavioral health needs. In this conversation, two experts from Intermountain Health discuss their "First 1,000 Days of Life" Initiative that provides wraparound services for at-risk new moms. Then, Lacey Starcevich, a former program participant, shares her emotional journey to building a healthy life for herself and her new family.


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00:00:00:25 - 00:00:33:19
Tom Haederle
Being a new parent is challenging in the best of circumstances, but it's even harder for expecting and new moms struggling with social and behavioral health needs. And living in a rural community means that the resources available to support new parents may be limited. The first 1,000 days from pregnancy to age two offers a crucial window of opportunity to create brighter, healthier futures.

00:00:33:21 - 00:01:17:00
Tom Haederle
Welcome to Rural, a yearlong series devoted to rural hospitals and health systems in America. I'm Tom Haederle with AHA Communications. St. James Health Care in Butte, Montana, now part of Intermountain Health, is designing care around new moms who need the extra support not just during pregnancy, but during the first two years of the baby's life. At this year's AHA Rural Health Care Leadership Conference, Julia Resnick, director of strategic initiatives at the AHA, spoke with April Ennis Keippel, community health director, Montana/Wyoming Market at Intermountain Health, and Joslin Hubbard, social worker at Intermountain Health at St.James Hospital, about how their first 1,000 Days program provides wraparound services for at risk new moms.

00:01:17:03 - 00:01:25:18
Tom Haederle
They were joined by Lacey Starcevich, a former program participant who shares her powerful journey to build a healthy life for herself and her family.

00:01:25:21 - 00:01:42:25
Julia Resnick
April and Joslin and Lacey, thank you so much for recording this podcast with us. We're here at the AHA Rural Health Care Leadership Conference. I'm really pleased to have all of you. So to kick things off, let's get a little background on your health care system. So can you tell us about Intermountain Health, St.James Hospital, and the community that you serve?

00:01:43:02 - 00:01:44:27
Julia Resnick
April, do you want to kick things off?

00:01:45:00 - 00:02:12:19
April Ennis Keippel
Sure. So we are a part of a large system, Intermountain Health, that includes hospitals in Montana, Colorado, Utah, clinics in Nevada as well. And St. James is located in southwest Montana. It's a community of about 35,000 residents, is a level three emergency department and really provides services for all the surrounding counties, which are primarily rural counties.

00:02:12:21 - 00:02:15:12
Julia Resnick
Anything else you both want to add about the hospital and your community?

00:02:15:12 - 00:02:30:04
Joslin Hubbard
Butte is a really proud community. It has a long history of mining and people are proud to be from Butte. They help each other out. They come together to support one another. And it's just a beautiful place to live.

00:02:30:07 - 00:02:44:00
April Ennis Keippel
And Butte was known as the richest hill on earth at one point and at one time was the largest city between Chicago and San Francisco in its heyday. So rich history in the community.

00:02:44:00 - 00:02:58:01
Julia Resnick
That is quite a history. And I love that piece about community because I think that's really what we're here to talk about. And our focus today is really on maternal health. So, Jocelyn, can you talk at all about the maternal population that you're serving and where your patients come from?

00:02:58:07 - 00:03:23:00
Joslin Hubbard
Yeah. So most of our patients live in Butte or Silver Bow County. We do serve the women from the surrounding counties as well. Our payor mix at our hospital is, you know, around 85% Medicare and Medicaid. And we have women primarily of Caucasian descent. And we serve ages, you know, teen age to later maternal - advanced maternal age, they call it.

00:03:23:01 - 00:03:26:06
Joslin Hubbard
So but just a really great mix of.

00:03:26:09 - 00:03:33:27
Julia Resnick
And even though most of your patient population does identify as white, are there any disparities that you've identified between like different subsections?

00:03:33:29 - 00:03:53:15
April Ennis Keippel
So a lot of the disparities we see in our community health needs assessment are actually related to socioeconomic status. Individuals living in poverty across all health outcomes have poorer outcomes. So anyone 200% or less of the federal poverty level just scores worse on a number of health outcomes.

00:03:53:18 - 00:03:58:29
Joslin Hubbard
April, Do you know what population of our patients fall within that 200% below poverty level?

00:03:59:04 - 00:04:05:24
April Ennis Keippel
The residents, I would say about 20% of overall residents. So one in five are below the poverty level.

00:04:05:27 - 00:04:19:22
Julia Resnick
Got it. And when you're thinking about these new parents in your community, are there any particular challenges that you've been seeing them experience? I know you touched on their socioeconomic status of needs, but in terms of behavioral health and how those challenges are impacting them.

00:04:19:24 - 00:04:46:18
Joslin Hubbard
So we have limited resources for our behavioral health and substance use. So those definitely impact our patients' access to care. When we're talking our socioeconomic struggles, it's even transportation to those appointments. It's housing, working with women and families. It's hard to talk about getting to appointments when they're not sure where they're going to live, you know, or stay that night or how they're going to get to that appointment.

00:04:46:21 - 00:04:53:07
Joslin Hubbard
You know, we have to take in all of that into consideration when we're dealing with people with substance and mental health needs.

00:04:53:10 - 00:05:01:00
Julia Resnick
Absolutely. So we're really here to talk about the Meadowlark Initiative. So can you talk to our listeners about what that is?

00:05:01:03 - 00:05:28:08
April Ennis Keippel
I can maybe start and then you can fill in as needed. So the Meadowlark Initiative is funded through the Montana Health Care Foundation. And it's really focused on providing intensive case management to the most at-risk patients prenatal and then following through til the second year of life. So, really helping to guide and support both prenatally and then also postnatal.

00:05:28:10 - 00:05:30:07
April Ennis Keippel
What else would you add, Jocelyn?

00:05:30:09 - 00:06:05:15
Joslin Hubbard
Yeah, so the initiative initially was funded by the Montana Health Care Foundation, but St.James has continued that, recognizing the need and the importance of this work. And so our program was the first 1,000 Days, which is from conception to age two, recognizing that it is the most critical and crucial time in human development. And when the brain develops, you know, it's just really using that care coordination piece to kind of bridge the gaps between those services, whether it's housing, food issues, transportation, mental health, substance use and the clinic or the hospital and how to connect patients when they come in for prenatal care with those outside resources, and then to continue to be

00:06:05:15 - 00:06:12:02
Joslin Hubbard
a resource and a support for them as they not only through their pregnancy, but as they embark on parenthood.

00:06:12:04 - 00:06:22:08
Julia Resnick
That's amazing that you have such a long perspective on it and not just, you know, a specific part of pregnancy or postpartum. So who are you partnering with or coordinating with to bring this all to life.

00:06:22:14 - 00:06:46:16
Joslin Hubbard
In terms of community resources? Yeah, Perfect. Yeah. So we have lots of you know, we partner with all of our resources in the community, whether that's private therapists. We partner with our Southwest Montana Community Health Center to provide mental health services as well as primary care following delivery. You know, our mental health centers and parenting agencies in the community as well.

00:06:46:18 - 00:06:53:24
Julia Resnick
So talk me through it...like someone finds out they're pregnant: how do they get enrolled in the program? Like, what happens next? What does that look like?

00:06:53:26 - 00:07:15:00
Joslin Hubbard
The hope is that they would seek prenatal care and come to an appointment. And at that appointment they would be screened for social determinants of health. So we would be screening for transportation issues, food insecurities, housing, as well as mental health and substance use. We would also be screening the partner or whoever is supportive of that woman in pregnancy.

00:07:15:02 - 00:07:28:25
Joslin Hubbard
So that we can really help the whole unit. And then they would meet with a care coordinator. And that care coordinator then would connect with resources and help identify needs, provide education, and then support throughout the pregnancy.

00:07:28:27 - 00:07:32:27
Julia Resnick
It's wonderful. And are there any stories you can share that can really bring this to life?

00:07:33:04 - 00:07:43:25
Joslin Hubbard
Well, I'm fortunate to have Lacey here today. Lacey was one of our moms in our program, and I think that she can speak to her story better than I could ever.

00:07:43:27 - 00:07:46:05
Julia Resnick
Great. Lacey, over to you.

00:07:46:07 - 00:08:11:12
Lacey St.arcevich
I'm Lacey. I just, on the 22nd of February, recently celebrate five years clean. I originally attended my first prenatal appointment actively using drugs. I was screened and obviously made the requirements for the program. At the time, I was homeless and still using. I left that first prenatal appointment not sure if I was going to get clean or not.

00:08:11:17 - 00:08:26:09
Lacey St.arcevich
Not even sure if I wanted to keep Bradon. That's my son's name. He'll be five in August, actually. So with the help of Jocelyn and the Meadowlark Initiative, I was able to connect with these resources and get help. And today I'm present for my children.

00:08:26:12 - 00:08:32:02
Julia Resnick
That's amazing. I'm just so glad you're here to share your story and that you've been involved in the program since, is that?.. Yes.

00:08:32:03 - 00:08:41:09
Lacey St.arcevich
Yeah. So anything I can do to help? There are just so many mothers out there who are in the same position I am. And it's an unfortunate situation. But with things like this, we can try to lower that number.

00:08:41:12 - 00:08:46:06
Julia Resnick
And I'm sure having contact with you helps them feel less alone and that, you know, there is a light at the end of the tunnel.

00:08:46:12 - 00:08:50:19
Lacey St.arcevich
You know, there's nothing more therapeutic than another addict helping another addict.

00:08:50:21 - 00:09:03:09
Julia Resnick
Wonderful. And I know that, you know, we have a great personal story of the impact of this work, but have you been measuring what the impact is on the women that are in the program? Yes. Yes, we have. Is there anything you can share?

00:09:03:11 - 00:09:06:28
April Ennis Keippel
If I look at my notes...I don't know off the top of my head.

00:09:07:00 - 00:09:31:28
Joslin Hubbard
We have found that women who participate in this program are more likely to have consistent prenatal care. They're more likely to take their child home at delivery. And that means from a lower involvement of the Child Protective Services Removals, women have better health outcomes to higher birth weights, lower complications, less hospital stays that are involved in the care as well.

00:09:32:01 - 00:09:44:24
Joslin Hubbard
And a lot of that's probably attributed to the more consistent prenatal care, as well as changing a lot of their lifestyle and ensuring that they have the food and resources that they need,  as well as you know, hopefully not using substances.

00:09:44:26 - 00:10:01:19
Julia Resnick
So to wrap us up, I love your words of advice for other rural hospitals that are really thinking about what they can do to improve their maternal and child health outcomes. What have you learned along the way that you can share with them? And Lacey, you'll have a slightly different version of that question.

00:10:01:22 - 00:10:30:04
Joslin Hubbard
You know, when we're dealing with rural, it's hard to find people to fill spots, right? And I think the most important thing is that we realize that this is just has to be someone who cares and who understands the community and the resources out there and who can show understanding and love and kindness to patients. There's not a magic wand. This is hard work, but it's, you know, it's done in partnerships and relationships that are built not only with the patient but with the community.

00:10:30:07 - 00:10:40:10
Joslin Hubbard
And, you know, just really taking time, stepping back, understanding what the needs of your community are and, you know, just addressing it one day at a time.

00:10:40:13 - 00:10:41:21
April Ennis Keippel
Well said.

00:10:41:23 - 00:10:43:26
Julia Resnick
Very well said, April.

00:10:43:28 - 00:11:10:09
April Ennis Keippel
I don't know if I could really add anything more to that. I think it just in looking at having a connector and a go-to person, I think is probably the most important thing so that there's a single point of contact that can help move forward any of the needs and make connections. And I'm not sure that that always would need to be a particular type of training to do that work.

00:11:10:10 - 00:11:22:25
April Ennis Keippel
So I think in a rural community you could customize it to really fit what you have available. But the key piece would be just to have that single person who can really help be the connector.

00:11:22:27 - 00:11:41:11
Julia Resnick
That human connection piece really just came out strongly in both of your answers. And Lacey, from being on the participant side of this and, you know, having been one of the moms in the program, what do you wish that hospitals knew about working with new moms who might need additional social or emotional support?

00:11:41:13 - 00:11:59:16
Lacey St.arcevich
We just need, you know, a setting that's not judgmental. We do not have a village. And programs like this help us create that village, and that sets us up for success. They help me create my family. They help not only me get clean and deliver a healthy baby, but my husband followed ensued because they provided us the resource to be able to do that.

00:11:59:19 - 00:12:00:22
Julia Resnick
It's wonderful.

00:12:00:25 - 00:12:16:03
Joslin Hubbard
I just wanted to call out Lacey. You know, not only does she have Bradon, but she now has a two year-old, Parker. She's married, has bought her own home, and is a role model for other women in our community and just so proud of where she is.

00:12:16:06 - 00:12:20:06
Julia Resnick
I'm so glad we can lift up your story and share it with the world.

00:12:20:09 - 00:12:21:03
Lacey St.arcevich
Thank you.

00:12:21:05 - 00:12:30:07
Julia Resnick
So, Lacey, Joslyn, April, thank you so much for joining this podcast. I look forward to seeing your presentation later today. And just congratulations on the fantastic work you're doing.

00:12:30:09 - 00:12:30:22
Joslin Hubbard
Thank you.

00:12:30:28 - 00:12:31:27
Lacey St.arcevich
Thank you.

00:12:32:00 - 00:12:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and read us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

 

 

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.


View Transcript
 

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.


View Transcript
 

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.


 

View Transcript
 

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.
 


 

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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.

 

 

 


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.

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