AHA's Rural Podcast Series

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00;00;01;02 - 00;00;29;26
Tom Haederle
Clinical care and community population health are two sides of a coin. One approach treats patients with procedures, medicines, Visits to the emergency room or as an inpatient. The other approaches broader in scope addressing behaviors, environmental conditions and social determinants of health that affect entire communities. As we continue the shift to value based care and see an increased emphasis on health equity, can the gulf between these two approaches be bridged in a way that benefits everyone?

00;00;29;29 - 00;00;57;28
Tom Haederle
Let's find out. Welcome to Community Cornerstones, Conversations with Rural Hospitals in America, a new podcast series from the American Hospital Association. I'm Tom Haederle with AHA Communications. Kevin Barnett is a senior investigator with the Public Health Institute and a board member for Trinity Health. In this podcast, he talks with The AHA’s Julia Resnick about what it will take for rural providers in particular to bridge the gap between clinical care and community population health

00;00;58;00 - 00;01;15;14
Tom Haederle
as providers cope with finite resources while addressing what it will take to improve health equity in their communities. Barnett says it starts with rural care providers having a deeper understanding of the full spectrum of services and supports that are needed in the community. With that, let's join Kevin and Julia.

00;01;15;16 - 00;01;41;17
Julia Resnick
Hi. This is Julia Resnick, director of Strategic Initiatives at the American Hospital Association, coming to you from the age Rural Health Care Leadership Conference in San Antonio, Texas. I am here today with Dr. Kevin Barnett, who is a senior investigator at the Public Health Institute as well as a board member at Trinity Health. So Kevin comes to this work with a public health lens and a health care lens, which I think makes you the perfect person to have this type of conversation with.

00;01;41;18 - 00;01;42;13
Julia Resnick
So welcome, Kevin.

00;01;42;18 - 00;01;44;01
Kevin Barnett
Delighted to be with you.

00;01;44;03 - 00;02;07;06
Julia Resnick
So what we really want to talk about today was how to resolve that tension between clinical and community as we're thinking about value based care and what it's going to take to improve health equity in our communities and really move into the future of health care. So before we dive too much into that, can you talk a little bit about your role at Trinity Health and what Trinity Health is doing in the value and equity space?

00;02;07;08 - 00;02;40;12
Kevin Barnett
Sure. Well, as you noted, I'm a member of the board for Trinity Health and and I was recruited for the board specifically because of the work that I have done for the last now 30 years in the community health arena. And my focus in this work has specifically been initially as it relates to hospitals, is to help these institutions be more strategic and thoughtful about how they allocate these resources with an eye towards producing measurable improvements of health in their communities.

00;02;40;15 - 00;03;06;12
Kevin Barnett
Now, in the early days of community benefit, it was often described as hospitals engaged in random acts of kindness, And those acts of kindness were nice to talk about, nice to report. But we did not often find a way to document them beyond the fact that we helped Mrs. Rodriguez and she's really happy as a result of this program.

00;03;06;14 - 00;03;57;18
Kevin Barnett
So moving from random acts of kindness to measurable improvements required folks to be much more thoughtful about the populations they're serving. Doing some front end analysis of where problems are concentrated in a way that we could effectively document more than impact upon very small cohorts. In that process and along the way, it began to emerge that much of what was going on was being done in a way that might be viewed as marketing, might be viewed as benefiting not just those who need it most, but signaling to commercially insured patients that we want to come to our hospital, that we're doing good things for them as well.

00;03;57;20 - 00;04;26;08
Kevin Barnett
And so there was a a backing away from that orientation. Let's disconnect what we're doing in our community from our marketing department and focus more on how we actually improve health status. So all of this is happening in a fee for service environment. And so the the only real argument for doing this work well was to say, let's be good stewards of these charitable resources.

00;04;26;08 - 00;05;04;22
Kevin Barnett
Let's make sure that every dollar that we spend in meeting our charitable obligations yields the maximum impact. And that begins to move the thinking towards how do we reduce the number of people coming into our emergency room for preventable conditions. And the more people that we can impact by taking more proactive, more strategic steps and the more we can leverage and build capacity in our communities of other organizations that we partner with to do this, then we are clearly making optimal use of our charitable resources.

00;05;04;24 - 00;05;47;10
Kevin Barnett
Now, we are still very much on that path. When you look at the community benefit expenditures of many hospitals across the country, there is still a preponderance of what they report as community benefit in the form of treatment of preventable conditions in emergency room and inpatient settings. However, it provides a perfect target in the context of moving to risk based payment, value based payment, whatever we call it, moving gradually towards establishing a budget for treating and caring for people and paying incentives.

00;05;47;12 - 00;06;04;13
Kevin Barnett
If people actually improve health and reduce treatment and prevention of preventable conditions in clinical settings. So that's the path that we're on. We have a ways still to go in that regard for a number of reasons, but I'll stop there.

00;06;04;14 - 00;06;23;01
Julia Resnick
Yeah, it's always struck me that there's really like this chasm between the world of community health and community benefit and what we're seeing in population health, where in population health is really focused on clinical care management and trying to address those community health needs clinically versus investing in communities, looking upstream, you know, getting outside of hospital walls.

00;06;23;04 - 00;06;29;07
Julia Resnick
And there have been efforts to bridge those. But how do we build that bridge? What does that look like?

00;06;29;09 - 00;07;16;06
Kevin Barnett
Well, we have to build that bridge first by ensuring that the people that we engage in this work are not only competent, but that we have alignment of incentives up the line to the senior leadership level of the organization, that these are the kinds of things that we do. As it stands now, to the degree that one can make the case as a director of community health or a VP for community health, the degree to which you can make the case that the intervention or interventions that you've designed will actually reduce preventable eating and patient utilization in many cases across the country, you're taking money out of the pocket of the hospital and your chief

00;07;16;06 - 00;07;47;04
Kevin Barnett
medical officer is going to say, what are you thinking? And so how do we how do we dig our way out of that? Well, we do that in part by beginning on this path of understanding where we're going and be in a position with payers and with others to negotiate for risk based payments that actually reward you for keeping people healthy and out of your emergency rooms in inpatient settings.

00;07;47;06 - 00;08;10;00
Kevin Barnett
So I'm not saying all of this happens in a very orderly way. Hospitals, I mean, there are many brave hospitals in health systems that are on this path, knowing that at least in the near term, it's not likely to yield significant returns on that investment in financial terms. But they recognize nevertheless that this is a critically important work that we're doing.

00;08;10;07 - 00;08;32;27
Julia Resnick
Yeah, And I think implementing those care models, whether or not you have the payment behind it to really truly incentivize it will be important down the line as those financial incentives align more. And I've always one of the things that's always fascinated me is like we talk about this move to value, but at what point in the fee for service versus value ratio does care actually change?

00;08;33;01 - 00;08;33;25
Julia Resnick
Does it like...

00;08;33;25 - 00;09;00;28
Kevin Barnett
Do I have a ratio in mind? I know folks talk about tipping points. Yeah. It's getting to 40, 50, 60% as being a point where where really changes behavior. But in those cases where we have moved more quickly, it it clearly changes behavior, whether you're talking about physicians or anyone in the care and in the care delivery process.

00;09;00;28 - 00;09;11;08
Kevin Barnett
Again, it requires courage on behalf of those in the senior leadership, and it requires board members that are asking the right kinds of questions. Mm hmm.

00;09;11;10 - 00;09;18;15
Julia Resnick
So I feel like as a board member, you can be an instigator of this. What kind of questions would you advise asking leaders?

00;09;18;18 - 00;10;04;07
Kevin Barnett
Well, for example, there is a lot of talk these days about ways in which we engage community health workers, promoters, whatever you would call them, as a way of extending our reach from the clinical setting and to understand what's going on in communities, what's going on in the home. And these are people with lived experience, people that understand their culture and are and know, for example, to ask the questions that in most primary care physicians might not know to ask of people. They might not be aware that Mr. Rodriguez is afraid to raise issues with the doc because she may be judged or I don't want to bother the doctor with these kinds of things.

00;10;04;09 - 00;10;35;13
Kevin Barnett
So community health workers represent a powerful extension of what we do in the clinical setting into understanding what's going on in the community setting. In most cases of community health worker engagement across the country, we're still sort of taking little steps and let's deploy two or three here and two or three there. And often without a linear line of sight to where are we going to go with this?

00;10;35;13 - 00;11;26;14
Kevin Barnett
If this works, then what? And how does this represent a definitive movement of the kinds of things that a community health worker could do that you would report as a community benefit, because it's clearly addressing real drivers of poor health in local communities. And at the same time, it it not only improves health status, not only reduces preventable ED and inpatient utilization, but it it ultimately yields more returns for the institution. Where this is being discussed, particularly the one of the more interesting developments in this regard in an important area of focus in my work is is how we can get hospitals and health systems who are otherwise competing in urban areas

00;11;26;16 - 00;12;21;19
Kevin Barnett
where they have overlapping service areas. And some of them, by dint of their location, are more proximal to low income communities, have more people on Medicaid coming into their emergency rooms than others. But they lack the financial wherewithal because of the fact that they are safety net institutions to invest substantially beyond what they already are. So to the degree that we can get other hospitals with whom they are competing, at least for the commercially insured population, not competing that well, mind you, but the recognition that they can come together and yield far more impact and far more scale, far more dose than they could then they can on their own.

00;12;21;22 - 00;13;13;07
Kevin Barnett
When we get to that point where we can demonstrate that, then not only will those systems be better positioned politically to push for other actions by whether it's a municipality or county and others to help really address those drivers of poor health. But we've also significantly improved the health status in our local communities. That's the we're sort of on the edge of considering what that looks like. I think this was encouraged by the pandemic and a recognition I, I have had multiple conversations with hospital leaders who said to me in the midst of the pandemic, I didn't realize just how difficult it is for the low income people in the community that I serve.

00;13;13;09 - 00;13;25;05
Kevin Barnett
So they're in the midst of a lot of other chaos and a national policy arena. I think there's a growing number of hospital leaders that really want to drop their bucket and do something solid in their own community.

00;13;25;07 - 00;13;45;26
Julia Resnick
I think they'll be really exciting thing to see both in the urban communities that you're talking about and the rural hospitals that are here. And I know that this work can can look different in a rural hospital because rural hospitals have different resources. The types of partners they have options to work with are different. How do you think rural hospitals can go about bridging that divide between community and clinical initiatives?

00;13;45;28 - 00;14;31;04
Kevin Barnett
Well, it is a shorter path in some ways for rural hospitals because they have such a smaller staff. They have such a small staff in many situations I where I've worked with rural hospitals, that the senior leadership is directly engaged, where in larger hospitals you're working with somebody well down the food chain from the senior leadership. And unfortunately, in this regard, not connected to strategic decision making and rural hospitals and more likely to have somebody who's a decision maker that you're engaging on these issues and as such, they're thinking about the survival of their organization.

00;14;31;04 - 00;15;07;07
Kevin Barnett
They're thinking about how this work that we're doing in the community directly relates to what we're doing in the clinical setting. So that's an advantage. Another advantage is, is because these are smaller communities, because there are less, for example, community based organizations competing for the same resources. You have more people that are used to wearing more hats and those people really have a deeper understanding and in many cases more sophisticated understanding of how we can come together and how we can leverage our limited resources.

00;15;07;09 - 00;15;24;24
Kevin Barnett
So those are all positive potentials. And mind you, it might sound like I'm trying to make light of of a of a very heavy lift for these these organizations. I don't mean to do that, but I it is important to reflect on the strengths that they do bring to the table.

00;15;25;00 - 00;15;31;08
Julia Resnick
Absolutely. And to empower them that they can do this work. And it is not out of reach even if they don't have the payment models in place.

00;15;31;09 - 00;15;32;06
Kevin Barnett
Absolutely.

00;15;32;08 - 00;15;42;06
Julia Resnick
So in terms of closing thoughts, like what is your vision for the future of rural America in terms of what its health care systems can do to improve health equity and community benefit?

00;15;42;11 - 00;16;28;20
Kevin Barnett
That's a great question. And in my most optimistic vision for that is a recognition that these institutions have a deeper understanding of the full spectrum of services and supports that are needed in a community. We're at a hospital association's conference, so we're talking about hospitals, but really the the vision for the future is for institutions that are capable of delivering the highest quality acute medical care services, but increasingly have the ability to deliver a broad spectrum and or collaborate with others to deliver a broad spectrum of services and supports that more proactively build health and well-being in our communities.

00;16;28;22 - 00;17;04;29
Kevin Barnett
That's the vision that I have for for the rural hospital of the future. That may mean that there will be additional acute care facilities in communities that close and or are converted to more multi-service centers. I think that's the more likely scenario. And I would just note there, as I have observed in and work in a couple communities just in this last year, that there was an opportunity missed to leverage what was a closed hospital.

00;17;05;01 - 00;17;25;13
Kevin Barnett
Because when you leave a building empty for any period of time, it will quickly become unusable, particularly facility like a hospital. So when we consider closing a hospital and we should consider what conversion of that facility might look like and not simply walk away.

00;17;25;15 - 00;17;36;05
Julia Resnick
So I think the path forward might be a little bit rocky, but there definitely is a path forward and we'll all keep leveraging our ingenuity and creativity for a bright future for rural health care.

00;17;36;07 - 00;17;40;00
Kevin Barnett
Well, it's rocky now, right? Hmm.

00;17;40;02 - 00;17;46;18
Julia Resnick
Mm hmm. Well, Kevin, thank you so much for joining this conversation. Really appreciate your all of your insights.

00;17;46;21 - 00;17;48;06
Kevin Barnett
Thank you. It's a pleasure to be with you.

00;00;01;01 - 00;00;25;24
Tom Haederle
The problems facing rural health care providers across the nation are well-documented. Squeezed budgets, lack of insurance, transportation and access issues, dwindling patient populations. One rural provider in Northeast Texas says, yes, all of that is true, but he still wouldn't trade places with any other hospital or health system.

00;00;25;26 - 00;00;57;16
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. Terry Scoggin is CEO of Titus Regional Medical Center in Mount Pleasant, Texas. It serves about 88,000 people and is the last independent system still operating in that part of the state. Scoggin and his senior team hope to keep it that way, independent and able to make its own calls about what's best for the community it serves.

00;00;57;18 - 00;01;22;07
Tom Haederle
Titus Regional is about people, roots and relationships. Scoggin says most people in town have his mobile number, something unheard of for CEOs of larger organizations. Titus Regional is proudly rural, unaffiliated with a larger health system and passionate about the care it delivers. As Scoggin says, every decision we make, we have to think about how it will affect someone we know.

00;01;22;10 - 00;01;45;27
Andrew Jager
My name is Andrew Jager and I'm director of Population Health at the American Hospital Association. I'm here today at the AHA Rural Health Care Leadership Conference in San Antonio, Texas, and it's my pleasure to be speaking with Terry Scoggin, CEO of Titus Regional Medical Center in Mount Pleasant, Texas. Terry, thank you so much for sharing some of your time with me and with the Advancing Health podcast listeners.

00;01;46;00 - 00;01;52;08
Andrew Jager
Could you start by telling us a little bit about Titus Regional Medical Center and what makes the community you serve so special?

00;01;52;14 - 00;02;13;06
Terry Scroggin
Thank you so much for the opportunity to share our story and share the rural story. Titus Regional Medical Center is the last independent health system left in northeast Texas. 35 counties make up northeast Texas. We're the last independent and we're rural. We're 60 miles from the Oklahoma-Arkansas-Louisiana border, right on I-30. So we're the definition of rural.

00;02;13;08 - 00;02;36;10
Terry Scroggin
Titus County is a hospital district. We are PPS. We range a census of about 50 on a daily basis. We deliver babies, about 950 a year; 22,000 a year in our emergency department. But we are independent, so we have the challenges of that. Titus County is 32,000. So we support Titus County and the four surrounding counties total. About 88,000

00;02;36;10 - 00;02;59;26
Terry Scroggin
total is what we serve. The next health system of any size is about 60 miles in all direction. So being independent, we're on our own. So we're always worried about being taking over competition of joining large health systems. Over the last seven years, I've seen four hospitals close within 45 miles of us. The rest of the hospitals joined large health systems.

00;02;59;27 - 00;03;20;20
Terry Scroggin
So you can see I'm passionate about it. We're passionate looking about independence and we rely on the American Hospital Association...Texas Hospital Association...TORCH, which is the law association for many hospitals in Texas for that independence and that ability to stay where we are. You ask what's special about our community? We're rural. You know, it's we've got a lot of hardworking people.

00;03;20;25 - 00;03;40;29
Terry Scroggin
We've got a lot of people who've pulled their bootstraps up on a daily basis. A lot of successful entrepreneurs. So they're supporting us with community standpoint. During COVID ... we're the largest county with COVID per 100,000 in Northeast Texas. How are we the lowest mortality rate? Not even close. And the reason why is we get involved in our communities and our physicians came to the table.

00;03;41;01 - 00;04;01;27
Terry Scroggin
So after COVID, we realized we can do this. We can stay independent. We made COVID decisions in East Texas, not in board rooms in Brentwood, Tennessee, or the East Coast or Dallas, Texas. And we need relationships with those larger health systems, but we need those decisions, final authority needs to be made by me and my board on a minute's notice.

00;04;02;00 - 00;04;24;18
Andrew Jager
Thank you, Terry. I love that sort of local control because because I think one of the thing that's really impressed me over the time that we've had the privilege of working with you and your team is the really innovative approach that you've taken to understanding both the strengths and the needs of the community that you serve. So I wonder if you could tell me just a little bit about some of the leadership tactics that you've used to develop your approach to the data?

00;04;24;18 - 00;04;38;23
Andrew Jager
Right? Both the quantitative elements that I know you all use and such a sophisticated way, as well as the the really useful qualitative type information that you pull in together through the relationships that you have with community organizations and with community members themselves.

00;04;38;26 - 00;04;59;29
Terry Scroggin
So to be independent, you have to understand your community and know a little bit about Titus County. That 32,000 people is 45% Hispanic, 44% white, 9% African-American. So you can see we're very different, a lot of cultures, and you have to take that into consideration. I focus on mortality a lot, and we look at it in Mount Pleasant, Texas.

00;04;59;29 - 00;05;21;03
Terry Scroggin
I'm going to live five years less than Dallas, Texas, seven or eight years less than my son in Austin, Texas. And that's what we focus on. So we talk about data. We're really wanting to turn from the normal benchmarks using the past and focus on outcomes data. And focus on the different segments, the Hispanic community, male, female, uninsured.

00;05;21;03 - 00;05;46;12
Terry Scroggin
We're 33% uninsured adults in our community. Texas is not extending Medicaid. We feel that on a daily basis in the rural health system. So we need to look at data in that way. What is the diabetic rates in issues for all different segments in our community? African-American, Hispanic, white, uninsured, insured? Data is not just a number anymore. Data has to be broken into.

00;05;46;14 - 00;06;14;04
Terry Scroggin
We're a primary heart attack center and a Level Two NICU, a Level Two maternal services and a primary stroke center. Each one of those groups on their joint commission accreditations are really now focusing not just on numbers anymore, but breaking the segments and outcomes. So really focusing on, you know, what's the rates for maternal that affect each one of our segments, African-American women, Hispanic women, and trying to understand those cultural differences.

00;06;14;06 - 00;06;38;20
Terry Scroggin
So data's changed. You know, I had the opportunity to participate with AHA years ago. Got to know the guys at my topia. They have a great software and he will become a friend of mine. Now and communicates. We use his data to really get into understanding our community. Mt. Pleasant is 16,000 people. It's small. You'll live more than ten years less on the south side of the town than the north side of the town when you break your town into census.

00;06;38;20 - 00;06;55;10
Terry Scroggin
And so there's so much data in there. Hardest part is where do you start? And that's where our challenge is daily. And we look to the experts and friends just to find out, you know, what are they looking at, how are they making it work, and then try and make it work for a community. You ask about how we interact for a community?

00;06;55;16 - 00;07;17;17
Terry Scroggin
We had a health fair on Saturday in our hospital. React quicker, save your ticker, our cardiac. Found out that for Black History Month, one of the churches was doing something. So about 2 hours in, I drove over the church and I knew the pastor and knew some things, but they were having a group on just the task force, and I sat down with them for the next two and a half hours.

00;07;17;19 - 00;07;35;26
Terry Scroggin
That's what's different. And, you know, had the opportunity to sit down with our leaders and our African-American population and understand about maternal services and the history of midwives in northeast Texas. It's totally different when you really go back 100 years and understand that. But if you want to know rural, you better know your history. So it's a little bit different.

00;07;35;28 - 00;07;49;13
Andrew Jager
Yeah, and you said it so well that right data is more than just numbers. So having that context and you're doing the measurement and the hard metrics, but having that contextual information to make sense of it is so important. So I really appreciate that.

00;07;49;20 - 00;08;09;09
Terry Scroggin
I want to give a shout out to University of Texas. I'm an Aggie class of '92, Texas Aggie band and core of cadets. I'm an Aggie. Had the opportunity to go to University of Texas this year from a master's in science in health care transformation and what the Dell Medical School and the Institute for Values are doing at Texas right now is unbelievable.

00;08;09;16 - 00;08;26;28
Terry Scroggin
Elizabeth and Scott are doing some great things in there. And I'm 53 years old. One of my board members asked, why am I going back to school? And you have to. I mean, have to understand and look at it differently. They're focused on outcomes changing our delivery system. And over the last six months, I still have six months to go

00;08;26;28 - 00;08;46;05
Terry Scroggin
so I may not pass, but, you know, it's been able to open my eyes and look at the different things about how we're doing it, how we're talking to our patient. What are those disparities across our health system? Rural is a disparity, let's be clear. But it's also economic status, gender. It's all the different things. So I'll give a shout out to

00;08;46;05 - 00;08;55;12
Terry Scroggin
University of Texas, they're doing it right. Dell Medical Schools partner with them and meeting some great people. But that's how we're going to change that and that's what we're going to do, is we have to look at the future differently.

00;08;55;14 - 00;09;22;25
Andrew Jager
Yeah, I appreciate that shout out there. There's so much impressive work going on there. So thank you. Speaking of impressive work, there's so many impressive speakers here at the AHA Rural Health Leadership Conference. And this morning in one of the plenary sessions, one of the speakers posed what I thought was a really interesting question. And that's, you know, what can America's rural hospitals teach their counterparts in urban areas or in large academic medical centers, about really understanding the needs and priorities of those communities that we serve?

00;09;22;27 - 00;09;36;05
Andrew Jager
So I guess I'd ask you the question, what could your urban and larger academic medical center colleagues learn from a hospital like Titus Regional Medical Center about engaging and understanding and really just kind of co-producing health through the community?

00;09;36;07 - 00;09;54;16
Terry Scroggin
The biggest thing for those larger health systems to understand is: they need to know what's personal. In a rural community - I've lived there 18 years and lived in Austin for 12, but I've moved Mount Pleasant 2004 to raise my boys when they were, 2,4,6 and 8. Now, no, it wasn't their home. They're gone. It's just me, my wife now, but it's our home now as well.

00;09;54;16 - 00;10;14;03
Terry Scroggin
It's personal. I go to church with these people. I see them at Walmart. I coach their kids. I was a concession stand. Booster club, school board. And these are the people you see at the grocery store, church on a daily basis. So when they have questions about their bill or they weren't able to get in or the doctor didn't, things didn't go right or somebody didn't treat them, they're picking up the cell phone and call me.

00;10;14;06 - 00;10;34;26
Terry Scroggin
The majority of the town has my cell phone. Most urban CEOs are not giving out their cell phone on a daily basis. At the health fair and actually at the Black History Month on Saturday, I walked around and gave these people I don't know some of the people, they have my cell phone now. If there's a problem, they're confused on a bill or they've got somebody who can't access, they can reach out to my cell phone.

00;10;34;29 - 00;11;02;00
Terry Scroggin
You're not going to see that, it's personal. We also don't have the ability to make a mistake. I don't have ... We're financially okay. Okay. We don't have anything to fall back on. If we do something stupid or we don't pay attention, it'll cost my community their independent health system. My team, which is amazing...I'm blessed to have an amazing staff and team members and friends around me and their physicians, but we don't turn it off. 24/7

00;11;02;03 - 00;11;24;15
Terry Scroggin
that's all we think about is our community. No matter where we go, you can't get away from it. It's tough sometimes, but it's a mission and you're able to affect people's lives. So that's the one thing I would tell our people is every decision we make, we have to think, how is it going to impact Darrell, Kirk, Amy, Michelle. It's just not segments of people.

00;11;24;18 - 00;11;40;06
Terry Scroggin
You know, we've got to understand how it's going to impact those individuals. And and I'm appreciative. I think I'm blessed to have them. I'd also tells urban people, as we need them to be successful. We need to get the people who used to work in some of the urbans and have some of the skill set around, especially quality.

00;11;40;08 - 00;11;59;03
Terry Scroggin
And we're a Leapfrog A now. Before COVID, we were Leapfrog C. See, we realized patient safety and quality through the high reliability organizations and a lot of stuff AHA does the importance of that. And we made a change, and I've invested a lot of money, money we don't have, in quality and patient safety, and we're Leapfrog A and we're doing some unbelievable things.

00;11;59;03 - 00;12;19;29
Terry Scroggin
And my CNO is thinking outside the box and trying to change the thing. So I'm appreciative of what she's doing. My CEO is doing some great things and physician groups, we're all having to be innovative and just hired a new CFO, excited to have him join us, but he was a board member. He also live in the community 50 plus years.

00;12;20;01 - 00;12;40;18
Terry Scroggin
He understands what we're trying to do. So having a financial mind who can work with all of us and knows the importance of what we are to the community. We're excited about our team and where we're going. And then you can't do without positions. I don't know if the urban counterparts really believe it and understand it. I think they think they can replace a physician.

00;12;40;25 - 00;12;58;17
Terry Scroggin
I can't. So I balance every day making that sure that physician has what they need, but also understands our mission vision. And we have to do a better job of recruiting and we recruit. We have to make sure. Do you understand what it means to be a physician in this community. So that's the long and short of it.

00;12;58;23 - 00;13;13;24
Andrew Jager
Yeah, I mean, it's personal, right? And it's personal. These are 24/7, but it's personal. And kind of living your values and your mission every day is the way you get it done. So I just want to thank you for your leadership, for the crucial work you do every day in your community. It's made all the difference. So thank you so much.

00;13;14;01 - 00;13;15;29
Terry Scroggin
Thank you for the opportunity for us to tell our story.

00;13;15;29 - 00;13;35;01
Andrew Jager
Yeah, this has been a lot of fun and I just want to let folks know we're listening that to learn more about some of the work that we're doing at the AHA to support hospitals, both rural and urban, in their population and community health efforts, please visit our websites at AHA.org/pophealth or Healthycommunities dot.org.

00;00;01;02 - 00;00;46;03
Tom Haederle
The creation of the Rural Emergency Hospital designation on January 1st of this year was intended to offer struggling rural hospitals a new financial lifeline. Converting to REH status allows Medicare to pay for emergency department and other outpatient hospital services without requiring the facility to meet the current Medicare definition of a hospital. It can mean upwards of $3 million in subsidies each year, but there is a trade off involved and explaining that trade off to patients can be a tricky business.

00;00;46;05 - 00;01;13;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. A rural hospital that wants to convert to the new category of Rural Emergency Hospital must agree to discontinue their non-emergency inpatient services. And that means that patients typically have to leave within 24 hours. Those who can't go home have to be discharged to a full service hospital, possibly in another state.

00;01;13;21 - 00;01;42;10
Tom Haederle
Conversion to REH is a decision with profound implications for the local community. Anson General Hospital in Anson Texas, roughly 200 miles west of Dallas, is among five hospitals that have made the change. In this podcast Anson CEO Ted Matthews and Chief Nursing Officer Anna Doan speak with the AHA's John Supplitt about how this new designation has worked out so far ... and what the local patient population thinks about the move.

00;01;42;13 - 00;02;02;07
John Supplitt
Good day. I'm John Supplitt senior director of AHA Rural Health Services and joining me is Ted Matthews, CEO, and Anna Doan, chief nursing officer, Anson General Hospital, Anson, Texas. And we're here to discuss rural emergency hospitals and how it works. Welcome Ted and Anna, to our podcast.

00;02;02;09 - 00;02;03;22
Ted Matthews
Thank you. Good morning, John.

00;02;03;27 - 00;02;04;21
Ted Matthews
Thank you, John.

00;02;05;01 - 00;02;32;04
John Supplitt
So just folks, so, you know, rural emergency hospitals are a new provider type established by the Consolidated Appropriations Act of 2021. And the purpose is to address the growing concern over closures of rural hospitals. The rules  were promulgated in June of 2022, and they went into effect January 1st of this year. And Anson General Hospital is one of five hospitals that recently converted to a rural emergency hospital.

00;02;32;06 - 00;02;59;08
John Supplitt
And what we want to do is explore their journey from concept to implementation. But before I do, let's share some background on Anson. The hospital district is about 200 miles west of Dallas, and the town has about 2000 residents. And the hospital was built under Hilbert and back in 1952. But the hospital Authority was created in 2016. So, Ted, how would you describe yourself today?

00;02;59;10 - 00;03;45;22
Ted Matthews
That's a good starting point, John. As you mentioned, 2200 residents in our community and the county where we sit, Jones County has not 10,000 residents. We're primarily farming and agriculturally based. The hospital is the third largest employer in the community we have approximately 55 FTEs. Per capita income... we have some socioeconomic issues here in our community. Again, per capita income is 22,000. 35% of our population is greater than 65 years of age.

00;03;45;25 - 00;04;27;00
Ted Matthews
So when we started this process as a rural emergency hospital, we really started looking at it back in June and July of 2022. We had board meetings and basically we had a soft needs assessment with certain individuals within our community because we realized the changes, especially having a geriatric population, and that with the loss of inpatient services and swing bed services, we realized that it was going to be a hardship on a number of our residents and the community.

00;04;27;02 - 00;04;46;03
John Supplitt
So originally as a 45 bed hospital, you featured emergency room services, surgery, diagnostics, lab, radiology, respite care, physical therapy, and you officially converted to Rural Emergency on March 27th. So how was the conversion received by the community when it was announced?

00;04;46;06 - 00;05;28;11
Ted Matthews
Well, John, we've had mixed reviews. Fortunately, for the most part, again, we've had some community meetings and explained this to our community. It allows us to continue to provide access to care. Our focus now is shifting away from the inpatient services that we offered and the swing bed services that we offer to our community, which were critical. And so what it means is that when one of our patients needs to be admitted, perhaps for pneumonia or for some of those other services, basically we can just keep them here for 24 hours.

00;05;28;12 - 00;05;55;15
Ted Matthews
So we're looking at observation stays on site. So we're going to have to transfer those individuals to Abilene as a larger community, 125,000 or so where they have the much larger hospital. But the problem is, again, the individuals, spouses and all that are going to have to be traveling that 30 miles to Abilene and then the 30 miles back.

00;05;55;17 - 00;06;05;17
Ted Matthews
So we are excited about providing services, but it's not the full spectrum of services that we had offered at one time.

00;06;05;20 - 00;06;25;27
John Supplitt
So people got accustomed to receiving a certain level of service and now that's changed. And it also means collaborating with the hospitals in Abilene for the transfers. Do you see this process moving forward evenly? Do you see people becoming more accustomed to the changes that are going to occur?

00;06;25;29 - 00;07;04;11
Ted Matthews
I do. You know, you really don't understand the difference until it affects you personally. And so right now we don't have a large flu population or etc. at this time, but we will during the winter months. And it's one thing in theory to understand the way something works, but entirely different when it affects you individually. We recognize the fact that we're going to be having those discussions with a lot of community members, again, the geriatric population that's wanting to know why their spouse can no longer stay in our hospital as they once did.

00;07;04;13 - 00;07;11;29
John Supplitt
Did you encounter any licensure or regulatory hiccups with CMS or the State Department of Health when you were making the conversion to Rural Emergency Hospital?

00;07;12;01 - 00;07;44;22
Ted Matthews
John, we really didn't it went very smooth for us. We started off out, of course, and had some help. And during all of that we followed up with a lot of documentation and this was all in early January that we started doing that. And then on March the 30th, we received notice that effective March the 27th, that our conversion, our new designation was going to be a rural emergency hospital.

00;07;44;22 - 00;08;20;24
Ted Matthews
And so that went very smooth for us. We had individuals in place. We received a new provider number and our old number of 71 years was no longer applicable. We had a new Peyton number, so we started that process. And by April the 20th, so we were we went on a Medicare and Medicaid hold at that point, and we had to move quickly because this decision was all primarily a financial decision on our part.

00;08;20;24 - 00;08;45;03
Ted Matthews
And to go a month without Medicare or Medicaid dollars coming in was going to be a challenge for us, even though we had financially prepared as much as possible. Again, it was a challenge for us. But by April the 20th, actually less than a month, we had our first facility payment and the hold on the Medicare dollars had been released.

00;08;45;05 - 00;08;56;14
John Supplitt
Oh, great, That's good to know. So the money is starting to come in. Have you received any of the monthly payments that are that are part of the payment process under Rural Emergency Hospitals?

00;08;56;16 - 00;09;19;03
Ted Matthews
We have. Yes. One little caveat there. We're still waiting on the Medicaid dollars to come in. They're still on hold. And this is probably of an answer that someone else could explain better than I can. But even though our Medicaid number will not change, it's tied to the MPI number, which is tied to our new Medicare number.

00;09;19;05 - 00;09;59;09
Ted Matthews
And so we hope to have those dollars released any time now. Under this new designation. I mentioned the facility fee, and that's approximately $274,000 a month, and that will help us. We have lost the inpatient reimbursement and we've lost the swing bed reimbursement. But the $270,000 monthly, approximately $3.3 million a year, should provide us enough funding to continue to operate. At the offset our inpatient numbers again and our swing bed numbers on a net basis.

00;09;59;09 - 00;10;23;12
Ted Matthews
That's about 2.8 2.9 million that we're going to get on an annual basis. And John, last year, this fiscal year just ended, we we lost 2.6 million. And so you can see from those numbers, the margin is extremely thin. And we're just going to have to be doing an exceptional job of being good stewards on the financial side.

00;10;23;14 - 00;10;45;15
John Supplitt
Well, I certainly can appreciate the pressure you're under financially as you move towards this transition. But hopefully this new model and its payment process will be a strong path for you to move forward. Anna, let's pull you into the discussion. You know, part of this responsibility is that you have to have a detailed action plan of services.

00;10;45;17 - 00;11;00;08
John Supplitt
So if you would, tell us what services you're presently providing and and clearly you've given up swing bed services, but then how did you arrive at the decision as to which services you would provide and where the physicians included in any of the decision making for this?

00;11;00;11 - 00;11;32;13
Anna Doan
During the initial conversations during the board meeting, we included our full time physicians in that conversation and they were both of them were on board with the decision to convert to REH. As you mentioned earlier, the two services we lost were inpatient services and swing bed services. So in our action plan we continued ... we have a three-bed emergency room, so we have for 24 hour emergency room services, we have laboratory, we have radiology that includes X-ray and CAT scan.

00;11;32;15 - 00;11;47;20
Anna Doan
We still have physical therapy as well as our rural health clinic. And then we're utilizing our observation services and our numbers are great compared to last year. Our numbers have been very good since converting.

00;11;47;22 - 00;12;12;20
John Supplitt
Well, that is encouraging. So CMS also established rules regarding access, safety and quality of care for Rural Emergency Hospital patients. And those are closely aligned with those of critical access. But you're also expected to implement a quality assessment and a performance improvement program. So how are you doing with respect to the quality and meeting the the conditions of participation upon conversion?

00;12;12;22 - 00;12;38;08
Anna Doan
This is for sure, an ongoing process. We're only the fifth in the nation to be able to get this certification. So we are in constant communication with CMS regarding what measures we're going to do and everything is just still up in the air. It's every statement as we will get back to you on this, when we have everything finalized, we will get back to you.

00;12;38;09 - 00;12;51;28
Anna Doan
So we're just doing our best to continue to provide excellent patient care and knowing that all we can do is the ER and observation within the hospital setting. And we're hoping we have a better understanding of all this in the next six months.

00;12;52;01 - 00;12;59;03
John Supplitt
So presently, then, what is the framework from which you're working in order to assure quality and patient safety?

00;12;59;06 - 00;13;34;04
Ted Matthews
You know, at one time, for example, we reported on HCAPS, we reported on DACA, we reported on hospital inpatient quality reporting, population and sampling, e-comm hospital acquired infections, etc. And a lot of those were tied to our inpatient census. And as Anna said, we realized we're going to continue to report on our emergency room and all of those outpatient services, but it's inpatient services.

00;13;34;04 - 00;13;58;07
Ted Matthews
And so what are going to be the new reporting metrics that we're going to have to address? And again, as Anna said, we have actually reached out to CMS and they said it's sort of their developing those for us. And so we just continue to report on what we can. And we're waiting for some feedback from CMS as we move forward on this.

00;13;58;07 - 00;14;13;02
Ted Matthews
So hopefully we'll have a better understanding and better answers in six months or so. But again, we have actually reached out to them and it's being developed as we speak.

00;14;13;04 - 00;14;34;11
John Supplitt
Well, and it is a work in progress. And I think we all have to understand that. So we're learning as we go, but we really appreciate the pioneers here, such as yourself, that are taking this on and have made the conversion to Rural Emergency Hospital. One of the things here, Ted, is that Medicare agrees to pay that additional facility fee in 12 monthly installments.

00;14;34;13 - 00;14;52;19
John Supplitt
But there's also an expectation that you'll be able to record and report how you use that money as part of the requirements for conversion. Do you have a process by what you've set up in order to explain to CMS how you're using these additional facility payments?

00;14;52;21 - 00;15;21;19
Ted Matthews
We are. We're setting that process up now. A part of those funds will go for staffing. I can tell you when we went through this conversion, we lost about 20% of our employees, which is unfortunately, you never enjoy making those type of administrative decisions, but we had to do so. So part of that will go toward employing payroll of our employees.

00;15;21;19 - 00;15;56;16
Ted Matthews
And the other part, we have capital needs that we need to make. And we just we're in the process of very slowly starting to do that, especially on the laboratory side. Radiology, we look pretty good. We have a new C.T. scanner that we rolled out, so we're getting a lot of good feedback on that. But again, limited capital expenditures, the needs to make payroll, and we are just trying very, very slowly.

00;15;56;16 - 00;16;03;04
Ted Matthews
But we are growing access to care and continuing to provide excellent services.

00;16;03;06 - 00;16;29;11
John Supplitt
This is all really very helpful for us to hear, particularly as we're learning along with you about the conversion to Rural Emergency Hospital. Anna said the volumes good that it's consistent with what you expected. You're looking at taking the the monthly payments and applying them towards wages, payroll, diagnostic sticks, capital, the basic infrastructure that you would need as a Rural Emergency Hospital.

00;16;29;14 - 00;16;36;17
John Supplitt
Let me ask you finally, what advice do you have for those that are looking to convert to an REH. Ted, why don't you go first?

00;16;36;19 - 00;17;10;09
Ted Matthews
Our decision to become a Rural Emergency Hospital was the for most was driven primarily and solely on the financial side. Our payer mix, our volume... when I say payer mix, you have to understand in Texas that we have the largest number of uninsured individuals in the state and by far in rural communities, probably at 22 to 23% of individuals who walk through our emergency room are uninsured or underinsured.

00;17;10;09 - 00;17;38;26
Ted Matthews
And even those who we move on the observation side are uninsured. So that is a number that we constantly track. We look at the cost of operating a facility. Again, we've been here 71 years. We know just about all of our patients on a first name basis. We provide that one on one care and that's exceptional care. But all of that comes at a high cost, dollar costs to us.

00;17;38;28 - 00;18;06;02
Ted Matthews
So when we sat down and started going through this, it really wasn't an option. Do we want to do it or do we not want to do it? It was the only option we had. In Texas, we've lost 26 rural hospitals, and rural hospitals are critical to our survival. 85% of Texas is considered geographically rural. We only have 15% of the voting block.

00;18;06;05 - 00;18;29;28
Ted Matthews
Again, we've lost 26 rural hospitals. And if we had not been able to convert to this Rural Emergency Hospital at this time, we would have been the 27th rural hospital to close. And that is why we did it. But rural health care is a challenge here, down here, and we just roll up our sleeves. We all do whatever it takes to make it work.

00;18;30;00 - 00;18;40;17
John Supplitt
So, Anna, how about you? What what advice do you have for those that are looking to convert as a nursing director, speaking to other clinical professionals and nurses, what what would you recommend to them?

00;18;40;19 - 00;19;13;14
Anna Doan
The hardest part was the initial laying off because that's what affected nursing services the most. But as far as my advice to other hospitals as a CNO, I think the main thing is just communication and education with my staff, knowing where the providers and the staff, what services can we provide. There's all of these services we can continue to do and to provide for the community, and they still have access to care here. And that provided reassurance to the staff and to the community just with simple education in conversation.

00;19;13;16 - 00;19;21;14
Anna Doan
When it was uncomfortable conversation, they were reassured that this is hope. This conversion provides us hope for our hospital.

00;19;21;16 - 00;19;48;27
John Supplitt
Well, and that's a great way to end our conversation. It's about communication, it's about education, about keeping your community and your staff informed of the decisions that are being made and why we're making them. And with the intent of providing a medical presence, including emergency services that keep the community safe and secure. I want to thank my guests, Ted Matthews, CEO and Anna Doan, chief nursing officer and San General Hospital Finance in Texas.

00;19;49;00 - 00;20;11;06
John Supplitt
Thank you both for walking me through your firsthand experience with conversion to a rural emergency hospital. The nation will be watching closely as you grow and evolve under this new model of payment and delivery. So we wish you every success in your effort and hope to learn more about how we can make this model better for patients, hospitals and the communities we serve.

00;20;11;08 - 00;20;20;10
John Supplitt
I'm John Supplitt, senior director of Rural Health Services. Thank you for listening. This has been an Advancing Health podcast from the American Hospital Association.

00;00;01;01 - 00;00;23;14
Tom Haederle
Sometimes having your back to the wall coaxes out the best effort. Some years ago, Mackinac Straits Health System was the 15 bed Critical Access Hospital serving Michigan's Upper Peninsula. It was in critical condition itself, operating on a cash reserve of just 3 to 5 days. But by making some very difficult decisions and pairing with some very strategic partners.

00;00;23;22 - 00;00;31;14
Tom Haederle
Mackinac Straits has really turned things around and today is in a much stronger position to deliver the health care its community counts on.

00;00;37;25 - 00;01;07;19
Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. Mackinac Straits Health System has worked with just about everyone, including local, state and federal partners, to save what had looked like a sinking ship. Locally, the Mackinac Tribe made a critical difference, donating both land and money that allowed the health system to undertake a badly needed expansion.

00;01;07;22 - 00;01;23;15
Tom Haederle
In this podcast, Mackinac President and CEO Karen Cheeseman describes the long and carefully planned out process that led to the final recovery of a rural health system. She is speaking with Samantha Borow, program manager of the Population Health Team with AHA.

00;01;24;08 - 00;01;44;16
Samantha Borow
Good morning. This is Samantha Borow from the American Hospital Association. I'm a program manager on the Population Health Team, and today I'm joined with our guest speaker, Karen Cheeseman. She is the president and CEO of Mackinaw Straits Health System in St. Ignace Michigan. Welcome to the podcast, Karen. So great to see you.

00;01;44;23 - 00;01;47;24
Karen Cheeseman
Thank you, Samantha. Appreciate the opportunity to be here this morning.

00;01;48;00 - 00;02;13;28
Samantha Borow
Sure. So we wanted to talk a little bit today about some of the topics we covered in our pre-conference session, which was on multi-sector partnerships for community investment in rural health. And yesterday you described your hospital's 20 year evolution and all of the successes and setbacks that happened along that way. So I'm wondering if you can just take a quick couple of minutes here to do a high level overview of that journey.

00;02;13;29 - 00;02;18;16
Samantha Borow
Where did you start? What were some key milestones and how did you engage the community in that process?

00;02;18;25 - 00;02;45;28
Karen Cheeseman
Sure. Be happy too, Samantha. Thanks for the opportunity here this morning. So I'll start with a little bit of background. Mackinac Staights Health System is located in the eastern Upper Peninsula of Michigan in a small rural community. And we started back in 1954. Little additional background. We're a 15 bed critical access hospital. We have an attached nursing home.

00;02;46;00 - 00;03;16;13
Karen Cheeseman
We have a number of specialists that are on our team and providing care. We have outpatient surgery as well as the rural health clinics. We started our journey in a very compromised state, operating on about 3 to 5 days of cash. We were that hospital that was identified on the map with a red star that was in a very critical state, and we had some difficult decisions that had to be made in order to move our health system forward.

00;03;17;04 - 00;03;48;09
Karen Cheeseman
So in order to do that, one of the first things that we had to address was the building itself. We were in a very dated building. We were landlocked. We didn't have the ability to expand on our current footprint. And we were having a very difficult time meeting the life health and safety codes. So we had to, in order to move forward, we had to develop a complete revamp of our strategic plan, and that included a new building to grow the health system.

00;03;49;04 - 00;04;23;11
Karen Cheeseman
So in order to do that, we began working very closely and at multiple levels on a local level, a state and a federal level to to begin plans to build the hospital. We ultimately determined that we would work with the U.S. Department of Agriculture, the small and rural development community funds to move us forward. We identified a series of of key points that occurred over about a ten year span, and that allowed us to secure the funding necessary to move forward.

00;04;24;02 - 00;04;50;20
Karen Cheeseman
So the first piece that we identified was the funding for the hospital itself and which we were successful in. A key piece along that journey was our relationship with our local tribal community. The tribe was instrumental in our our journey and our ability to move forward. They donated the the land that the hospital sits on today. So 16 acres.

00;04;51;02 - 00;05;15;10
Karen Cheeseman
They also made the first significant financial contribution allowing us to move forward. So if you look back and you look at how the hospital was operating at that time on a very limited supply of cash, that was really critical, a very critical step to allow us to move forward. As we looked we identified the needs. One of the critical needs was also our nursing home, which was very dated at the time.

00;05;16;02 - 00;05;44;26
Karen Cheeseman
And it was time to provide an appropriate setting for our residents and her and our families doing the right thing at the right time for the community. So we had to make a decision. If we would have constructed our outpatient surgical center first, it would have enhanced our revenue stream quickly, which was needed. However, we felt that the nursing home and the needs that were present at that time were more important.

00;05;45;14 - 00;06;11;19
Karen Cheeseman
So we made the decision with our leadership team and with the support of the board and the trustees to construct the nursing home. We knew that the outpatient surgical services would follow and that revenue would would come at the right time. And that's exactly what we did. And we've not looked back on that since. As outpatients surgery moved forward, we were able to to really grow, and that's where we really saw things begin to take off.

00;06;12;08 - 00;06;47;06
Karen Cheeseman
We were able to recruit the specialists to the system and allow that center to to move forward successfully. Two of the things that I touched on yesterday also that were key to that growth was a strong orthopedic service line, along with a spine program both up and running and very successful today. And all of these things that I touch on are important because if we weren't providing that care in our community, our community would be driving great distances to seek that care upwards of anywhere from 50 to 100 plus miles.

00;06;47;23 - 00;06;55;01
Karen Cheeseman
So anything that we can do locally in the community is removing those barriers for care for our patients.

00;06;55;16 - 00;07;12;10
Samantha Borow
Thank you so much for that overview. It's so great to hear the story of your journey. One thing that you touched on was those strong partnerships with the community in order to better serve them so I'm wondering if you could talk about that a little bit more. How did you build those relationships? How did you rebuild those relationships?

00;07;12;10 - 00;07;21;21
Samantha Borow
As we know, this work all depends on strong foundations of mutual trust. So if you could talk a little bit more in depth about that journey with the local community.

00;07;22;01 - 00;07;48;17
Karen Cheeseman
Sure. I think you're looking back, the the relationships were critical in our success. And I mentioned the tribal component earlier. One of the first things that that got us up and running in this process and the tribe was in a similar situation that that we were at the time. They were very restricted on space. They also wanted to grow their services.

00;07;48;26 - 00;08;19;10
Karen Cheeseman
And so throughout those discussions in those strategic planning sessions, it was determined that we could really work together for the benefit of our community and without duplicating services. And I think we've done a a really great job at doing that. And not only I think it's really important to say and to point out it's important that you build the trust, but you also have to work to maintain and keep that relationship going.

00;08;19;23 - 00;08;44;03
Karen Cheeseman
And again, I think a great example of the things we've been able to do over the last several years. Along with that, we we had a number of different partnerships at the local level. We also worked with our state partners and our federal partners. We relied on our Michigan Health and Hospital Association for guidance throughout the process.

00;08;44;04 - 00;09;16;28
Karen Cheeseman
We also worked very closely with the Michigan Center for Rural Health, both great partners to us. We joke that we are the hospital that has had Senator Stabenow visit the greatest number of times. She was one of our significant champions of health care who can relate to rural health and in our needs. And she again strong supporter and really helped us attain some of our funding and helped us navigate the complexities of the funding throughout the last several years.

00;09;17;14 - 00;09;44;26
Samantha Borow
So thank you so much for sharing this journey that you've been on. It is so important to have that support coming from a variety of both the local community and all of the government systems that are at play here. So it's great to hear that you were able to build that strong coalition. If you were to start this journey again today, or if you know someone that is, you know, a rural hospital leader that's looking to do this, what sort of strategical or tactical advice would you offer knowing now what you should have known then?

00;09;45;13 - 00;10;13;05
Karen Cheeseman
I would advise to to really work hard to leverage your relationships at multiple levels, use your team and your resources wisely. Use your legislative teams and support mechanisms, state and federal, local, all of the above. Be prepared to hear no at times, and be prepared to continue to work hard for what's right for your community in the health care that they deserve.

00;10;13;20 - 00;10;21;11
Karen Cheeseman
Again, be prepared to get knocked down and get back up and look for partners who are going to support you in this journey.

00;10;21;17 - 00;10;43;11
Samantha Borow
Wonderful. And we know the value of partnerships. So it's so great to hear that you've put those together for your system and again, doing the right thing for your community has been front and center in all of your work. So just one last question for you is that we know that right now workforce challenges are really something that are facing hospitals across the United States right now.

00;10;43;25 - 00;11;01;16
Samantha Borow
So we heard yesterday that you've managed to attract a lot of staff and expand your clinical service lines and by really focusing on the needs of your workforce. So if you could just talk a little bit about what tactics a leader should consider when trying to address those workforce challenges at their own systems.

00;11;01;29 - 00;11;32;05
Karen Cheeseman
Workforce is certainly a challenge right now for for all of us. A very common thread throughout as we look at how we rebuild health care over the next number of years. I think it's really important to look at doing things differently. I remember years back when we actually had waiting lists for individuals, potential employees who are looking to join the organization and certainly things look a lot differently today.

00;11;32;21 - 00;12;03;16
Karen Cheeseman
So I think it's important to look out and knowing what you once did will not be what you do moving forward. So how can you get innovative and creative to attract the workforce that you need? I think cultures speaks volumes for employers today. So again, what type of employee do you need to support you or your culture in the care that you were delivering are really important and be flexible.

00;12;03;21 - 00;12;31;03
Karen Cheeseman
Maybe you're looking at, you know, a hybrid type of work scenario. Maybe you're looking to provide some additional flexibility for a young mother who may not have childcare. Maybe you're looking to provide support for an employee who is caring for an aging parent. I think all of those things have to be looked at and and considered today. And I think we have to have a tremendous amount of flexibility.

00;12;31;16 - 00;13;00;15
Karen Cheeseman
I think we also have to look at what we can do to grow our own programs internally where prior say, we may have been able to rely on external certification programs, maybe lean a little more heavily on our local community colleges and universities. Today, we're all fighting for the same labor pool and the same resources. So as we're looking out at Mackinaw Straits, we're looking at what we can do internally to grow our own program.

00;13;00;28 - 00;13;24;28
Karen Cheeseman
So that may include a nurse aid training program to support the nursing home. That may include a medical assistant apprenticeship program that will support our rural health clinics. That may also include a nurse resiliency program where we are partnering very closely with our first year hires for nurses, where we know that time period is really critical for retention.

00;13;25;16 - 00;13;44;01
Karen Cheeseman
So I think we can't limit ourselves to one or two things. I think it's a variety of things that we have to look at going forward. And I think we have to be very prepared to be nimble and adjust to our environments and expect that that will change frequently as we rebuild our workforce over the next several years.

00;13;44;10 - 00;14;10;00
Samantha Borow
Yeah, So the creativity and the innovation and the tenacity that you have is something to be admired. So thank you so much for coming and to join us today and share your thoughts and your experiences. We invite those who are listening, who are interested in learning more about community investment to visit AHA's page. We have a lot of resources from leaders across the country in a variety of settings, and we are constantly evolving that page.

00;14;10;00 - 00;14;18;08
Samantha Borow
So please continue to check back with us there. aha.org/communityinvestments. Thanks again, Karen, so much for joining us.

00;14;18;11 - 00;14;19;08
Karen Cheeseman
Thank you for having me.