AHA's Rural Podcast Series

00:00:00:09 - 00:00:21:21
Tom Haederle
Distance and lack of transportation. Obtaining a prescription and then paying for it. These are just some of the challenges that make accessing mental health and addiction services especially difficult in rural communities.

00:00:21:24 - 00:00:43:01
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Access to quality care in rural communities often presents problems that defy easy solutions. Still, there are workarounds, as we learn in this podcast hosted by Rebecca Chickey, the AHA's senior director for clinical affairs and workforce.

00:00:43:04 - 00:01:06:17
Rebecca Chickey
Indeed, it's an honor to be here today with Brenda Romero. I have known her for over a decade now. She is a past member of AHA's Committee on Behavioral Health, our national advisory committee that helps us with our advocacy and policy, as well as resource work. And that's why Brenda is here today as a CEO of a small rural hospital in New Mexico.

00:01:06:19 - 00:01:31:21
Rebecca Chickey
She has a great deal of experience, some of which she's going to share with you here today about improving access to mental health and addiction services in a small rural community. So, Brenda, welcome. Thank you for sharing your time and expertise. My first question to you is, what are a couple of the biggest challenges to accessing behavioral health in a rural community?

00:01:31:25 - 00:01:37:09
Rebecca Chickey
For those many, many listeners who live in an urban, metropolitan area, help them understand.

00:01:37:11 - 00:02:09:20
Brenda Romero
The first issue is access to the care in that rural communities don't usually have taxis. Transportation is an issue. And for people who are suffering from this illness, they're usually couch surfing or living out in the streets. And so finding them and getting them to the care is usually the first issue that we encounter. And the second is getting them the medication. The cost

00:02:09:20 - 00:02:38:15
Brenda Romero
of the medication can be up to $500 a month. And getting them the prescriptions is one thing, but then getting them the medications is another. Usually people with that presentation don't have a payor source, and so then it would require somebody giving them that money and willing to support that every single month. In order to increase compliance with medication treatment

00:02:38:20 - 00:03:03:26
Brenda Romero
we have started using some medications, like Brixadi, that we can give in the ER or in our infusion center, and it'll last a whole month. And we're using that type of medication for pregnant women that present and that we're not sure if we're going to see again for some time. And so that's been helpful.

00:03:03:28 - 00:03:27:15
Rebecca Chickey
So I'm going to hit home with a couple of things that you said for people who live in Chicago or New York or even Nashville, Tennessee, where I lived for a number of years. The fact that there's not a taxi is really sort of like, what? And I suppose that same lack of transportation services, you don't have an abundance of Uber drivers or Lyft drivers in your community either, right?

00:03:27:16 - 00:03:53:11
Brenda Romero
No, it's not available. And when you're talking about where these patients need to come from, we are in Espanola and there's about, there's less than 10,000 people that actually live in the city. And then there's Rio Arriba county, and it can be 100 miles to one of the borders. So we're talking about they come from surrounding communities. So it's not like somebody can walk there.

00:03:53:13 - 00:03:55:13
Brenda Romero
They need to find a ride.

00:03:55:15 - 00:04:18:17
Rebecca Chickey
And so that means relying on family or friends who may or may not also have transportation services. So just that physical capability of getting to the hospital or the emergency room is a challenge that many of our listeners probably can't imagine, but I can. Having grown up in rural Alabama, when EMS tried to get to my father, they couldn't find the house because there was no GPS at that time.

00:04:18:19 - 00:04:49:26
Rebecca Chickey
The next thing that you mentioned is the cost of the medications. So that's not unique to mental health. There always seems to be an article in the news or a discussion somewhere about the cost of medications, but these medications are for our most fragile patient populations because they often, and please correct me if I'm wrong, but they often have physical comorbidities as a result of or perhaps one of the reasons that they may be self-medicating with substances.

00:04:50:03 - 00:04:56:29
Rebecca Chickey
So their physical health and their mental health are often fragile and being challenged. Is that an accurate statement?

00:04:57:01 - 00:04:58:09
Brenda Romero
Yes.

00:04:58:11 - 00:05:16:02
Rebecca Chickey
And so because of that, tell me why it's so important to be able to provide a medication that lasts for a month. Is that to know that you don't have to worry after that because of compliance issues, because the patients are actually going to, they don't have to worry about that then.

00:05:16:05 - 00:05:48:23
Brenda Romero
Yes, it's not only compliance, but it's actually getting the medication. And so usually they don't have a payor source so they don't have Medicaid. And if they have Medicare due to a disability, they usually haven't signed up for part D or any of the other parts that they need to get payment for the medications, for prescriptions. And so if they were to try to go get their medications and be compliant with that, most times they wouldn't even get the medications because they can't pay for them.

00:05:48:26 - 00:06:07:24
Brenda Romero
And if a family member is willing to start them on it, like pay for the first month, it's pretty hard to get somebody to commit to just continue to pay for that. In order to get them on Medicaid, they would have to then get all the paperwork in order to apply. And they can apply online.

00:06:07:24 - 00:06:28:24
Brenda Romero
But some of these older folks don't have the capacity to be able to do that. They don't have the phone. They don't have the experience with getting on a website and filling in all the information that they need. And some of that information that they might need is to upload a copy of the birth certificate, and they might not have the birth certificate.

00:06:28:26 - 00:06:37:12
Brenda Romero
So the barriers are huge for them. They can't get there. And so I think that...

00:06:37:15 - 00:06:40:28
Rebecca Chickey
So what's your solution? What have you been creating, what have you been innovating.

00:06:40:28 - 00:07:01:18
Brenda Romero
So what we've done is we've started the treatment in the emergency room and then following them up in the clinic. And if we can get them started on medication, then we can buy more time to work with peer counselors, to work with case managers to help them get what they need in place in order to continue the treatment.

00:07:01:21 - 00:07:29:00
Brenda Romero
We are also encouraging the homeless shelters to work with the homeless population and to get them to our E.R. if they can do that. Presbyterian Healthcare Services, organization I work for, is now also asking if our paramedics can start giving out some of the medication when they respond to a call, if the patient is willing to start the treatment at the time.

00:07:29:07 - 00:07:37:17
Brenda Romero
So we're trying to figure out how to get the medications to folks where we can, even if they can't afford to do it.

00:07:37:19 - 00:08:04:08
Rebecca Chickey
So it sounds like you're taking advantage of every opportunity where there's a touchpoint with a patient that has this need. Yes. That's phenomenal. It's, I think, a broader sense of patient-centered care. You're going to where the patients are and providing the services. So do you think this innovative idea is replicable? Can it be implemented by other organizations in a similar crisis situation?

00:08:04:08 - 00:08:11:23
Rebecca Chickey
I would say because the challenges that you described almost seem insurmountable. But do you think others could replicate it?

00:08:12:00 - 00:08:35:21
Brenda Romero
Yes. Also, keeping in mind that, especially at the beginning, they're not going to have a payor source, right? So we're going to have to start that and not be reimbursed for that. But it makes a huge difference, not only most importantly to that person's life. Right? Like, who wants to be suffering like that? And then it starts improving their participation in society

00:08:35:21 - 00:09:02:27
Brenda Romero
and with their family members. And in our area it's a very family-oriented area, and most people who don't have a place to live will have a place to live if they sober up. And so reuniting those patients with their families is just, it would be an amazing thing to do. And then their reentry into their communities would be another win for everybody, right?

00:09:03:00 - 00:09:25:08
Brenda Romero
And makes it a safer place for the patient and for the communities that they live in. And so I think it's very, very important. I think it's worth it to everybody. There's something in it for everyone. And I think that one way to start is to assess what the barriers are, what are the barriers that those patients in your community are experiencing.

00:09:25:08 - 00:09:37:07
Brenda Romero
Because as you said, bigger communities have transportation. They have other ways to get around. So the patients in their community might not have the same barriers that we have in ours.

00:09:37:14 - 00:09:59:26
Rebecca Chickey
Yeah. As you were describing the long-term impact of this, if an individual gets on a medication that helps them remain sober for a month, then that gives them hope, then they may be able to get traction to go back and live with their family. Then they may be able to get a job. And that is something that is priceless, right?

00:09:59:29 - 00:10:26:15
Rebecca Chickey
You can't really put a price on giving someone their humanity back. But at the same time, the reality is that often no margin, no mission. So I realized that this is a new innovative initiative that you undertake, and so you probably haven't, you don't have hard data on that. But I would assume that what you're hoping is that you're going to see fewer emergency room visits, which we all know are costly.

00:10:26:17 - 00:10:54:12
Rebecca Chickey
I assume that you're going to have less use of emergency services outside, sending someone out to rescue someone who is in a crisis from a substance use disorder. And perhaps even you will see a reduction long term in things like cirrhosis, in things like congestive heart failure, in wound care for individuals, depending upon what the substance is. Is that what you're hoping for in the long run?

00:10:54:15 - 00:11:21:19
Brenda Romero
Yes. But most importantly, saving people, saving people's lives, right? They are at risk of death every day, premature death every day. And there's a lot of violence that's, you know, associated with this diagnosis. And so not only the patient's life, but their family and friends and other community members walking around. I mean, it would improve all of that also.

00:11:21:21 - 00:11:33:08
Rebecca Chickey
So it's a population health approach, I agree. Thank you. So much, one, for the work that you're doing. Boots on the ground, making a difference in individuals' lives. And thank you for sharing that inspiration with us here today.

00:11:33:10 - 00:11:34:27
Brenda Romero
Thank you.

00:11:35:00 - 00:11:43:10
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:15 - 00:00:24:23
Tom Haederle
In 2022, more than 49,000 Americans took their own lives. Beyond the tragic loss of someone who might have been saved by seeking help in time, suicide has a domino effect, leaving devastated families and communities in its wake. Suicide happens across every sector of society and there are resources available to help. But for farmers in rural areas, accessing those resources is especially difficult.

00:00:24:26 - 00:00:39:10
Tom Haederle
That's why Farmer Angel Network in central Wisconsin has stepped up to help.

00:00:39:12 - 00:01:07:26
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Farmer Angel Network is a support group founded to tackle suicide prevention, as well as assist loved ones who are coping with it after the fact and steer them to resources that can help. In today's podcast, hosted by Jordan Steiger, senior program manager of clinical affairs and workforce with AHA, we learn more about the group's important work and how area hospitals are contributing to the effort.

00:01:07:28 - 00:01:22:14
Tom Haederle
Jordan's guests are Brenda Statz, cofounder of Farmer Angel Network, Carey Craker, who handles marketing and volunteer services at Reedsburg Area Medical Center, and Christy Updike, transformation program manager with Sauk Prairie Healthcare.

00:01:22:16 - 00:01:45:12
Jordan Steiger
Brenda, Christy and Carey, thank you so much for joining us today on the Advancing Health podcast. We know that it is Suicide Prevention Month. We really want to shed light on the work that our members and our communities across the country are doing to bring some awareness about the issue of suicide, and I think the work that all of you are doing in your community in Wisconsin is really exceptional.

00:01:45:15 - 00:01:57:27
Jordan Steiger
So, Brenda, I'd like to start with you as one of the founders of the Farmer Angel Network. Could you please just tell us more about what the Farmer Angel Network is and what inspired you to start this initiative in your community?

00:01:57:29 - 00:02:16:21
Brenda Statz
We are just a group of people that started out at our church. I had lost my husband to suicide, maybe six years ago coming in October. And we started a support group of people to come in through our church. The president of the men's club, who was a friend of my husband's, wanted to do something.

00:02:16:21 - 00:02:38:05
Brenda Statz
And so he said, I just want to call people together to come in and talk, and that's how it started. And so the ladies of the church did a soup and sandwich luncheon, and we did it from noon to two, because that's when farmers usually come in to eat. And we put it out to Pam Jahnke on Channel 3 News and said, hey, we're having this gathering at Saint Peter's Church in Loganville.

00:02:38:07 - 00:03:04:05
Brenda Statz
Anyone who wants to come and talk or just needs someone to listen, or just wants to find out what's, you know, if something's going on in their life that they want some help with, they should show up. A lot of events we go to, we show up, and our main goal is to provide resources to the rural communities. Because when I went through it with my husband, everybody afterwards said, well, you could have gone here, you could have gone checked into this.

00:03:04:07 - 00:03:30:00
Brenda Statz
I didn't know any of that existed. And so I thought, this is some way that we can help other people and other families. And that was another big key to me was, for me, was to support the families, supporting those going through the crisis because they're already in trauma also. And that trickles down to the kids, all the way down, because it is a domino effect that affects everyone.

00:03:30:02 - 00:04:00:21
Brenda Statz
And so we try to bring resources to everyone to support the whole family. So, if the person does have to go into a treatment facility, by the time they come home, we can have the families supported. Because, like on a farm especially, somebody still has got to do the work whether you're there or not. And so if that person, like when my husband would go, that fell on me and my sons to do the cropping and get everything done while he was in the hospital. And the guilt that they have of not being there. But yet, they can't function where they're at.

00:04:00:21 - 00:04:18:18
Brenda Statz
So, that's what I always told them. You need to go where you can get help because we can't help you here on the farm. So that's your job now, to go get help. And so then he would agree to go, and we would take care of what needed to be done on the farm. But sometimes that can cause a lot of resentment to the other farm members

00:04:18:18 - 00:04:48:03
Brenda Statz
if it goes on for a long amount of time, because everybody gets tired; everybody gets stressed out. And if you don't teach them how to handle that stress, by the time that person comes home, they might be in a good place. Everybody at home is not, and that can just spiral out again. So, if we try to get everybody on a good place before they come home or whatever the situation they have going. That is our biggest goal that we have is just to bring resources, so people realize they are not alone.

00:04:48:06 - 00:05:16:23
Jordan Steiger
You've brought up so many important topics, I think within suicide prevention and just that introduction of the work that you do. I think, you know, surrounding the family and making sure that other people are empowered to take care of themselves as they're taking care for their family member that might be struggling. But one of the things that you really brought up, that I think maybe people in urban areas don't know as much, is just that stress that farmers face and those risk factors that come up for farmers and their families.

00:05:16:25 - 00:05:25:21
Jordan Steiger
So, I'm wondering if you could expand on that a little bit and just tell us about some of the unique things that farmers and farming communities face when it comes to mental health.

00:05:25:24 - 00:05:46:24
Brenda Statz
Stress is one of the number one things, but the biggest stressors they have is the weather. We can't change the weather. YouÕve got hay to make, youÕve got corn to plant. Everything relies on good weather or it's too dry. Last year we had a drought. I mean, we had half the crop or less because it wouldn't grow once you put the seed in the ground.

00:05:46:26 - 00:06:07:15
Brenda Statz
The other stressor we have is markets, totally out of our control. We have to take the price that is offered unless you work for a contract[BM1]. You know, there's ways that you can do that. But there's a lot of farmers that don't have access to that or just don't understand how to use the systems. And then other stress too, is just, having time to yourself. Time away,

00:06:07:15 - 00:06:30:18
Brenda Statz
time to get away from the farm, trying to relax somewhere. Because when you live where your job is, you never are off the clock. When you live in town, you work your job, you go home. When you're on a farm, you're at your job all the time, and you can never walk away. And so you have to teach people how to take time for themselves.

00:06:30:20 - 00:06:33:00
Christy Updike
I would add to that, if that's okay.

00:06:33:08 - 00:06:35:20
Jordan Steiger
Yeah, absolutely. Jump in, Christy.

00:06:35:23 - 00:07:05:29
Christy Updike
Couple additional things, are the transitions in farming. So many are family farms, and that transition to younger generations or having to sell or get out of farming are huge stressors and crisis moments for many people. That's a big risk factor that they're going through that. Another is access to guns or deadly weapons. So that is a standard part of living on a farm.

00:07:06:01 - 00:07:34:02
Christy Updike
It is a tool that we have to utilize. And unfortunately, that can be a risk factor in the farming. And the last one is isolation. So much of what farming is with the animals and the fields, and we don't have as many opportunities for fellowship. And that's one thing that Farmer Angel does, is to help bring farmers together to help address that isolation.

00:07:37:06 - 00:07:55:17
Jordan Steiger
I'm really glad you brought up isolation, because I was just going to ask Brenda about that. That was the first word that came to my mind when she was describing, you know, putting together this, this meal and, kind of fellowship at the church, you know, is just having that opportunity to come together, we know, is so important for mental health.

00:07:55:19 - 00:08:20:19
Jordan Steiger
It sounds like that's something that doesn't naturally always happen for people in farming communities. So, I think that, again, underscores the importance of the work that you guys are doing. So, I'd like to transition now and talk to our hospital leaders a little bit about how this actually works within the community. So, Christy and Carey, both of you represent two different hospitals, who work together as part of the Farmer Angel Network.

00:08:20:21 - 00:08:37:17
Jordan Steiger
I love to see when hospitals kind of come together for a common cause, and work across the organization to do something good for the community. So, I'd love for you to explain the role that hospitals play in this greater kind of network of work and the types of services that you provide.

00:08:37:19 - 00:09:07:24
Christy Updike
Sure, I'll start off with that and then Carey can jump in. To start with, Carey and I are both part of farming families as well. So, we have our professional roles and represent our organizations, but then also have our personal roles in being part of farming. And many of the people that we serve in both of our hospital service areas are either farmers, farm families or farm workers.

00:09:07:24 - 00:09:37:06
Christy Updike
They're part of that agricultural community. So, what we do as hospital partners with Farmer Angel Network is to offer our own resources as a part of our professional roles, to help the network coordinate the activities to achieve their mission. So, for example, in my role, I serve on board for the network and bring in the resources we have from the hospital. Whatever

00:09:37:06 - 00:10:18:26
Christy Updike
that might be, my time, the tools and resources, other experts. We also are able to support with expenses or resources like materials and printing materials, which Reedsburg Area Medical Center has done, as well as Sauk Prairie Healthcare. And we cohost and comarket our events. We have also trained our health care providers. So, with the collaboration with Farmer Angel Network, we've brought in different trainings for suicide prevention and for caring for farmers.

00:10:18:28 - 00:10:50:21
Christy Updike
And then we offered a continuing medical education collaborative with our entire county. So, all health care providers and behavioral health care providers in our county that are working toward suicide prevention on how they can best understand the farmers they care for, and practical strategies to help with suicide prevention, mental health care. So, I think with that, Carey can jump in as well.

00:10:50:23 - 00:11:26:19
Carey Craker
Sure. Just to expand a little bit on what Christy said. We help get the resources out there to our rural communities. As with any support group, you have times when things don't get better or when things escalate beyond what our group can help with. Reedsburg has both emergency services for crisis that's available 24/7 and a dedicated and growing behavioral health team thatÕs comprised of people from the rural community who understand rural living, farmers and rancher perspective.

00:11:26:21 - 00:11:51:09
Jordan Steiger
One thing that you both just brought up was that kind of cultural awareness around, you know, making sure that your providers and your behavioral health providers are aware of some of these things that we're talking about, you know, that could really affect farming communities. I'm a licensed, clinician myself. I'm a social worker, and I can tell you I did not learn in social work school how to care for these types of communities.

00:11:51:09 - 00:12:17:18
Jordan Steiger
And I think it's something that is really important to understand if you're going to be in that situation. So, I think that offering the CME credit, like you mentioned, offering that training at lots of different like lengths and, you know, over different times, I think is really probably very effective for, for you. Carey, I'm wondering if you have any advice for other rural hospital leaders who might say, like, wow, this program and this work is incredible.

00:12:17:18 - 00:12:20:24
Jordan Steiger
I want to start this in my community. What would you tell them?

00:12:20:27 - 00:12:48:04
Carey Craker
I think the biggest thing is going off of what we call our community needs health assessment. It's done nationwide and for the last, I don't know how many years, mental health has been at the top of the list. And so between us, Sauk Prairie Healthcare and the other hospitals in the area, it's the top of our conversation whenever we're looking at what do we need to do to help the community?

00:12:48:08 - 00:13:03:05
Carey Craker
So, the biggest thing, I think, would be, you know, to come together. We're not standing alone where hospitals in small communities who need to band together to help this mental health need.

00:13:03:08 - 00:13:32:17
Jordan Steiger
I think that's great advice. Again, just, you know, we're not in silos. I guess that's kind of a farming pun. I didn't mean that, but we should be working together. Not even just with other hospitals, but, you know, other community organizations, other groups across your, you know, your county, your region. I think that you guys have really done a great job of not staying just within the hospital or staying within a church or staying within these small entities, but really coming together.

00:13:32:20 - 00:13:49:14
Jordan Steiger
As we wrap up, I'd like to just turn it back to Brenda. I want to thank you for starting this and having the courage and the foresight to say that this is something that your community needed and using the loss that you endured to help other people. I think itÕs a really beautiful thing.

00:13:49:16 - 00:14:10:03
Brenda Statz
When it comes to this, like we are a network and that's why we are called the Farmer Angel Network. I always say, if one of us doesn't know something, we might know somebody who does. So, we all work together to get to the end result, which is to help the family or to help those that are struggling. And there is a lot of training. I've done mental health, first aid responder and safe talk training.

00:14:10:06 - 00:14:29:05
Brenda Statz
And that's what we've done with the hospitals. And the one thing I give them as advice is when a farmer finally decides to come in, don't just brush them off because it's going to take 15 minutes before they finally come forward with why they're there, because it takes a lot [BM2]for them to leave the farm because they've got 100 things to do.

00:14:29:05 - 00:14:44:06
Brenda Statz
So, they have to be in a really bad place before they will come in. And I said, they're going to walk in your office and they're going to talk about the dog, the weather and everything else. And then when you'll say, well, I guess our 15 minutes is up, and then they'll say, wait a minute, I've been struggling with this.

00:14:44:06 - 00:15:22:17
Brenda Statz
It takes time for them to gain your trust because a person with mental health, like with my husband, it takes a long time before you can trust someone to tell them that they're struggling with something like this, because farmers are fixers and they try to fix it themselves, and they wait so long to go in. But once they get in and they get the right tools or medication or whatever they need to help them navigate what they've got going on in their life, they do respond that much better once they've let it out, that they need help. And we just need to just, really, just listen because sometimes they just want to be heard.

00:15:22:19 - 00:15:39:12
Jordan Steiger
Sometimes just a very easy conversation to say, hey, I'm not doing okay. It's just the gateway that you need. I think everyone listening to this is going to be able to take something away, and we really appreciate the work that you're doing on behalf of all of our hospitals and all of the people that you serve. So, thank you.

00:15:39:16 - 00:15:40:21
Christy Updike/Brenda Statz overlapping 
Thank you. Thank you.

00:15:40:24 - 00:15:42:16
Carey Craker
Thank you, Jordan.

00:15:42:18 - 00:15:50:29
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:00:18 - 00:00:20:26
Tom Haederle
Experts say at least one in five children or adolescents in a pediatric waiting room is dealing with a significant mental health problem — everything from serious eating disorders to suicide attempts. Nationwide, there has long been a critical shortage of trained care providers to meet the needs of kids struggling with these issues. And the problem is especially acute in rural areas.

00:00:20:29 - 00:00:42:06
Tom Haederle
So it's encouraging to see that the most rural academic health system in the U.S., New Hampshire's Dartmouth Health, has created one of the most innovative and effective programs anywhere to provide the tools to help.

00:00:42:09 - 00:01:09:27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Sitting near the border with Vermont, Dartmouth Health serves a population of nearly two million people across many small towns in northern New England. Backed with a federal grant, Dartmouth has created a five-part virtual behavioral health training program for children and adolescents that offers care providers effective tools to engage and help guide young people through their challenges.

00:01:09:29 - 00:01:37:00
Tom Haederle
The program is called Keeping Students Safe: Supporting Youth in Mental Health Distress. In dialogue about the program with Jordan Steiger, AHA senior program manager for clinical affairs and workforce, are three experts from Dartmouth Health. Dr. Julie Balaban, child psychiatrist, Jackie Pogue, research project manager with the Dartmouth Institute for Health Policy and Clinical Practice, and Barbara Dieckman, director of Knowledge Map and patient education.

0:01:37:02 - 00:01:53:18
Jordan Steiger
Julie, I'm wondering if you can kick this off being that you are a child and adolescent psychiatrist, but we know it's been all over the news that since the start of the pandemic, a lot of children and adolescents are really struggling with their mental health. So could you kind of just paint the picture for us of what that's looking like right now?

00:01:53:25 - 00:02:21:09
Julie Balaban, M.D.
Yeah, I think there's actually been a problem with meeting the needs of children and adolescent mental health for a long time, because there's always been a critical shortage of mental health providers in general, and specifically for children and adolescents in that area of specialty. And then the pandemic really highlighted that the kids that were coming into the emergency room were seriously ill.

0:02:21:11 - 00:02:43:17
Julie Balaban, M.D.
Significant eating disorders, very serious suicide attempts. That's what was showing up during that time. And I think that really brought to light that this was an area of great need for a long time. So it's been well known that historically, that one in five kids in a pediatric waiting room, for example, will have a significant mental health problem.

00:02:43:17 - 00:03:10:14
Julie Balaban, M.D.
That number may now be higher, maybe one in four. And depending on what region you live in of course. The other piece that the pandemic played into is of course the general workforce shortage. So nursing shortage, for example, is a problem that's been affecting things like inpatient beds for kids who might need a psychiatric hospitalization. So hospitals have had to decrease their bed size.

00:03:10:14 - 00:03:34:05
Julie Balaban, M.D.
And so that led to a backlog for kids who were seriously ill, having to be in emergency rooms or even waiting at home. At Dartmouth, we had the luxury of being able to put some of those kids, at least up on a pediatrics unit, so they were around other kids and not in a general emergency department, which can be a scary place for a kid.

00:03:34:07 - 00:03:58:09
Jordan Steiger
Absolutely. And I mean, I know that this is a problem that is affecting communities, hospitals, health systems across the country. We hear it all the time at AHA. You know, we need to provide support to children and adolescents. I know you mentioned some pretty severe things like suicidal ideation, you know, severe and persistent mental illness that we know can continue to get worse when they are not treated.

00:03:58:11 - 00:04:14:27
Jordan Steiger
What I love about the work that you all are doing is that you're not just sitting back and saying, this is bad, what are we going to do? You've taken the steps to do something about it, and kind of brought your entire community and state along for the ride with you. So I would love to hear kind of what you're doing.

00:04:14:27 - 00:04:25:11
Jordan Steiger
I know that you have a virtual behavioral health training program for children and adolescents, and teaching people how to respond. Is that correct? Jackie? Can you tell us a little bit more about it?

00:04:25:11 - 00:04:49:09
Jackie Pogue
Sure. So we received a grant from HRSA around training rural behavioral health workers, very broadly defined. And we knew we wanted to focus on youth mental health. But, you know, we can't, like, grow a bunch of new psychiatrists in three years or, you know, things like that, we're trying to think creatively about where might be points of intervention that could have a bigger impact.

00:04:49:12 - 00:05:32:04
Jackie Pogue
So we met with a lot of different stakeholder groups, a lot of people from schools. So school counselors, school principals, other folks hearing about how youth mental health was impacting kids at school. So it could be things like really disruptive classroom behavior, kids who are kind of languishing, like just showing up but not thriving, right. A lot of kids wandering the hallways and hearing some of those stories, and also educators and people on the school staff, like really trying to work together for the increased severity and number of kids who were in having mental health challenges.

0:05:32:05 - 00:05:55:22
Jackie Pogue
So through those conversations, we developed, five-series training called Keeping Students Safe: Supporting Youth and Mental Health Distress. And we designed the program so that way to kind of fill some of these gaps that we heard from the schools. So they're like, well, they said they're very sick, but they went to the hospital and they sent them home.

00:05:55:24 - 00:06:17:06
Jackie Pogue
Like, why didn't they admit them? They're still so sick, or, oh, they went to the hospital and they came back and they're still really having problems, like what's going on. And so we realized there were, there are these kind of siloed systems, and to be able to share information and, you know, sort of promote more collaboration and give people more tools.

00:06:17:09 - 00:06:45:11
Jackie Pogue
What's been interesting is sort of helping people learn about all the skills they already do have, you know. I think there's a lot of fear from people that they're gonna say the wrong thing or that they don't have the tools, and not everybody is going to administer like a Columbia scale around suicide severity, right. But like especially school staff, I mean, they're amazing, you know, they're like, yeah, I talk to this kid every day.

00:06:45:11 - 00:06:55:27
Jackie Pogue
We do a check-in. We do these things like so just helping them feel more confident and that there's more details on it left out. Julie or Barb, what what else would you add?

00:06:56:00 - 00:07:26:16
Julie Balaban, M.D.
I think you did a great job, Jackie, of describing. I think what I would add is each time that we do the program, we learn from what our experience is, so that we can fine tune the content to better address what's coming up from the participants as what their needs are. And I think the other really nice aspect of the way the program runs through the I ECHO format is this all teach, all learn model.

00:07:26:19 - 00:07:55:04
Julie Balaban, M.D.
So not only, as Jackie said to people already innately have a lot of skills that they can bring. They just don't realize that it's useful. But they also all have a lot of help and support for each other and very practical resources. You know, we'll hear schools from the northern part of the state talking about something that they're doing, and then someone in the southern part of the state will connect with them offline to find out how they could implement the same thing in their school.

00:07:55:10 - 00:08:17:04
Julie Balaban, M.D.
So it's just been a wonderful way to build connections and networks that otherwise would never have happened, and all in the name of supporting youth in their schools. And our hope being that with those added resources and support, that kids will do better sooner and won't get to that severe level where they need to go to the emergency room or need to access things.

00:08:17:12 - 00:08:23:21
Julie Balaban, M.D.
But we also tell them how to handle that and what they have available to support them if they should need to.

00:08:23:23 - 00:08:52:06
Barbara Dieckman
I would agree with both of you. You know, I think that the ability to intervene in a kid's life earlier or in their where are you beginning to see some problems at school and having people that have those natural relationships with kids actually do something or be able to reach out and touch them is really helpful. I think just to decrease the demand on the whole acute care system.

0:08:52:08 - 00:09:17:26
Jordan Steiger
Absolutely. And I love, you know, through this program, you've kind of addressed some of those workforce issues that we hear about, maybe not directly, you know, but bringing people in like a coach, like a school nurse, like a principal, people like you said, Barb, that have contact with these children every day, that know them, that know their lives and can intervene, I think, takes so much stress off of the local health care system, as you all have mentioned.

00:09:17:29 - 00:09:37:07
Jordan Steiger
And I think that's so important because as you said, Jackie, we can't grow psychiatrists on trees. That's going to take a little time to build the workforce. So this is, I think, just such a great example that others can emulate and really implement in their own states. But I'd love to hear a little bit, maybe about some of the positive outcomes that you've seen.

00:09:37:15 - 00:10:21:23
Jackie Pogue
So we've done this five, it's a five-session one hour Zoom like every couple weeks. Usually. So we've run that five times. We've probably had 500 total people participate. It's been very, very popular. And some of the outcomes that we've heard, we do a pre/post course survey and we do a follow-up three months later. So things that people talked about are feeling more confident that they could intervene with a student in distress, that they knew the resources that were available and that they felt more confident interacting with youth's families as a resource and also other community resources.

00:10:21:26 - 00:10:57:29
Jackie Pogue
One outcome that we're really proud of is that, like 100% in every session, people talk about having a decreased sense of professional isolation. And so that is really powerful for us, knowing that people are, you know, just like in health care, school staff are very stressed. They've had a really hard time from the pandemic and now, and to be able to provide an opportunity for people to connect, to not feel so alone, right, that there's resources and there's hope has been really very meaningful I think for our team.

00:10:58:01 - 00:11:15:28
Jordan Steiger
That's great. I think, you know, sometimes we all get in our own bubbles and lanes and think, oh, we are the hospital. We can only solve problems for patients and families once they walk through the doors. But I think this proves that there are a lot of ways to partner with your community and to really improve the way that we respond as a whole.

00:11:15:28 - 00:11:28:20
Jordan Steiger
And I think that's really, really powerful, especially when we're talking about maybe smaller rural communities that we do know have some issues sometimes with workforce, with access, with things like that. I think this is just such a great example.

00:11:28:23 - 00:11:56:13
Jackie Pogue
Yeah. With youth mental health, it's just, it's such a crisis, right. And it's really an all hands on deck situation. And there's so many areas where people can act. And so that's really you know, when I think about the stats, it's really sobering. And then I think about all the caring school staff and community youth supporters and other folks that I have, that we've met through our Project ECHO.

00:11:56:15 - 00:11:58:09
Jackie Pogue
It really gives me a lot of hope.

00:11:58:11 - 00:12:19:09
Julie Balaban, M.D.
Yeah, I think one of the things that was an unexpected outcome for me, anyway, was hearing from the community, you know, we know this is a crisis and I come at it particularly from a clinical perspective. And what are we doing and how are we seeing these kids, and what kinds of things can we do to increase access to specialty care and all of that?

00:12:19:12 - 00:12:45:19
Julie Balaban, M.D.
And then talking to not just the schools, but particularly when we did the community programs, town libraries, we had a lot of librarians participate, and the stories that they tell about what they're doing and how they're trying to hold these kids together and what they have to manage in their setting with even less support than a school setting would have

00:12:45:21 - 00:13:09:21
Julie Balaban, M.D.
for example, it really opened my eyes to how this problem is just not just pervasive, but is really affecting people in the community so strongly, even if it's not the family member of the kid or the school trying to educate the kid. Like everybody is experiencing it, everybody is struggling. It was really something.

00:13:09:24 - 00:13:16:22
Jordan Steiger
That is. What other types of professionals were involved in that community ECHO that you ran?

00:13:16:24 - 00:13:57:03
Julie Balaban, M.D.
So we had some faith leaders from the community. We particularly ended up with our panel trying to include more of the community members for that reason, because we previously had had a lot of school people because we were dealing with school. And then of course, the hospital psychologists and myself and the typical sort of providers for kids. But we've very much have learned that if we're doing a program for a particular group of stakeholders, you need to have representation from that group on your panel, or you'll miss the boat in a number of things, even if it's just like when to schedule the sessions.

00:13:57:05 - 00:14:12:07
Julie Balaban, M.D.
So we had faith leaders, we had the coaches, we had rec department people, we had a daycare provider participate. People from some of the like, family support centers throughout the region. Those kinds of people.

00:14:12:09 - 00:14:37:15
Barbara Dieckman
You know, I would add to that, what is so good about doing this in a virtual way is that people didn't have to come to a meeting, central location. We've got mountains and you know everything else, right? And like every other rural community, there's distance, right? And there is hardship in terms of transportation and getting time off. None of that had to happen.

00:14:37:23 - 00:14:53:13
Barbara Dieckman
I mean, what we were able to do is to bring these people together from very disparate areas geographically to talk about something that they all cared about, and they all had very similar themes of need and solutions for each other.

00:14:53:15 - 00:15:12:10
Jordan Steiger
I think that's really powerful and especially like you mentioned, just, you know, addressing some of those, you know, transportation, some, you know, that distance between people, I think is something that I think many people will resonate with that are listening, you know, finding easier ways to connect people. And I think you guys have done that really, really well.

00:15:12:12 - 00:15:22:20
Jordan Steiger
As we wrap up, if you maybe have inspired somebody that is listening to, you know, implement something like this at their own hospital or health system, what advice would you give them?

00:15:22:23 - 00:15:49:00
Julie Balaban, M.D.
I would say do it. You know, we used a particular program that I ECHO program because Dartmouth has joined that group. But you can do this without any sort of a formal program. In our presentation, in our handouts, we particularly put a lot of that information because we want people to be able to emulate it within their own setting with whatever they can do and whatever resources they have, and it doesn't have to be costly at all.

00:15:49:03 - 00:16:14:16
Julie Balaban, M.D.
So I would say just jump in and do it. And I think, again, I think the important pieces are to go to the group you're trying to reach and hear from them. As Jackie talked about what they see as their needs, because we had guesses about things. But I think we did a better program because we worked from their perspective and what they were telling us.

00:16:14:19 - 00:16:24:18
Julie Balaban, M.D.
And then also to keep that good representation on your planning committee and on your panel so that you're really keeping a nice, well-rounded group going.

00:16:24:20 - 00:16:29:12
Jordan Steiger
Great, thanks Julie. Barb, Jackie, any advice you'd want to share?

00:16:29:14 - 00:16:43:01
Barbara Dieckman
Know that you can make a difference. Know that you can make a difference and just keep keep doing it. Keep improving. Keep looking for ways to hear from the people that are your audience. You can do it.

00:16:43:04 - 00:17:05:29
Jackie Pogue
I would add, you know, I think Project ECHO is a really great training platform and format, but like Julie said, you don't need to do Project ECHO to do a good program. And the things that I really value about ECHO and what we've been doing is you don't need to have a bunch of fancy experts like talking, talking, talking, right?

00:17:05:29 - 00:17:33:11
Jackie Pogue
The beauty of a more interactive, all teach, all learn there is the sense that you're relinquishing some control over your program, but it ends up providing space and being more powerful, I think. And that is, that's just how adults learn, right? Like giving each other advice and ideas and stuff that you can apply right away. So, you know, I've facilitated all the sessions.

00:17:33:11 - 00:17:52:11
Jackie Pogue
It's super fun for me to just, you know, don't know what people are going to say. And, in that way, yeah, it's just it's really rewarding. So I would say even if you're not going to use Project ECHO, I would encourage you to if you're going to do a session, have half of it be something where the audiences interacting and sharing with each other.

00:17:52:14 - 00:18:10:20
Jordan Steiger
I love that all teach, all learn model. I think that is so effective and just want to thank all of you again for joining us. I think the work that you're doing across your state is truly phenomenal. And like I said, something that others can really learn from. So we appreciate you sharing. And Julie, I know you mentioned you put some notes in your presentation.

00:18:10:20 - 00:18:17:03
Jordan Steiger
We can make sure maybe to add those to the podcast description so others can also learn from that. As long as that's okay.

00:18:17:03 - 00:18:18:01
Julie Balaban, M.D.
That would be great.

00:18:18:01 - 00:18:21:12
Jordan Steiger
Wonderful. So thank you so much again.

00:18:21:15 - 00:18:29:23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;19 - 00;00;22;29
Tom Haederle
Imagine getting an email or a phone call from a total stranger with this message: "I have your medical information and I know that you had surgery on this date." Pretty scary stuff. We've seen a sharp uptick this year in the brutal tactics of cybercriminals, who are now directly contacting and threatening patients during ransomware attacks, pushing the boundaries as never before.

00;00;23;01 - 00;00;48;26
Tom Haederle
As always, the bad guys demand payment and if a victim resists, they may threaten to publish sensitive photos online, take advantage of stolen patient records, or even send phony incident reports to the local police to trigger a harrowing visit from a SWAT team. Yes, that's happened too.

00;00;50;06 - 00;01;20;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA communications, John Riggi, AHA’s national advisor for cybersecurity and risk talks over with two experts how this latest despicable tactic in the arsenal of cybercriminals should be managed starting with updating incident response plans. As John notes, if there were ever any question that the intent of these gangs was to harm patients, it is now clear that is their fundamental intent.

00;01;20;22 - 00;01;45;21
John Riggi
Hello everyone, and thanks for joining today. I'm John Riggi your national advisor for cybersecurity and risk at the American Hospital Association. Today we'll discuss a new cybersecurity trend. Cybersecurity criminals are contacting and threatening patients during ransomware attacks. And there is a need to update incident response plans to adjust for the uptick in this despicable criminal behavior.

00;01;45;24 - 00;02;31;11
John Riggi
Unfortunately, last year was the worst year on record for data theft attacks and ransomware attacks. Foreign-based bad guys, primarily Russian ransomware gangs, are continuing to evolve their despicable tactics to increase the likelihood of payment by victims, including calling victims directly based on information in their stolen health care records, demanding payments from them directly, and/or conducting swatting attacks, dispatching local police to fake armed incidents at those homes of patients, which is very, very dangerous for the patients and responding law enforcement, and also threatening to publish very sensitive photos of patients online.

00;02;31;13 - 00;02;56;11
John Riggi
So, as you can see, they are pushing the boundaries directly, threatening patients. If there was ever any question that the intent of these gangs was to harm patients, it is clear now that is their fundamental intent. Today I'm joined with Jake Milstein, chief marketing officer at Critical Insight, and Johnathen Inskeep who was the former CIO at Caribou Medical Center.

00;02;56;13 - 00;02;59;12
John Riggi
Jake and Johnathen, thanks for joining the podcast.

00;02;59;15 - 00;03;00;14
Jake Milstein
Thanks for having us, John.

00;03;00;14 - 00;03;01;21
Johnathen Inskeep
Yeah, thank you.

00;03;01;23 - 00;03;12;00
John Riggi
Jake and Johnathen. Let's jump right in. Can you help our listeners understand what cybercriminals are doing during ransomware attacks and how they affect patients?

00;03;12;00 - 00;03;38;09
Jake Milstein
I think you, you know, you hit on some of the attacks that just occurred, but I want to go back actually a couple of years here, and recognize that this has been a criminal tactic in sort of a spotty way. You know, you go back 3 or 4 years and there was an attack on a school district in Texas, and that attack on the school district in Texas, the school district, I don't know, they either didn't pay quickly or decided not to pay.

00;03;38;11 - 00;04;02;20
Jake Milstein
And the criminals started calling parents and emailing parents and saying, oh, I know your son's name. I know your daughter's name. And of course, the parents started calling the school district. We saw it in health care a couple of years ago, but it was kind of spotty. The big change here is at the end of 2023, we saw it several times.

00;04;02;20 - 00;04;27;10
Jake Milstein
We didn't just see it one time. We saw it at a health care organization in Oklahoma, and then we saw it at Fred Hutch Cancer Care Center, which you talked about, which is in Seattle. And in the Fred Hutch case, the criminals went so far as to threaten these swatting attacks. The swatting attacks are when the criminals would, you know, they threatened to call 911 and say, you know, this person has kidnaped me and I'm in the basement.

00;04;27;10 - 00;04;48;27
Jake Milstein
Send the SWAT team, right? So the SWAT team would come. And you know, how might it affect patients? I mean, wow, can you imagine getting an email as a patient? You know nothing about cybercrime. And all of a sudden, you know, somebody emails you and says, I have your medical information and I know that you had surgery on this date.

00;04;48;29 - 00;04;52;05
Jake Milstein
You know, I mean, that's pretty scary stuff, right, Jonathen?

00;04;52;07 - 00;05;11;17
Johnathen Inskeep
Oh, absolutely. I just try to put myself in the shoes of, like the patient. If you're receiving those phone calls, you start to wonder. It's like, is this really happening to me? And then you start like, how did you get my information? And, you know, they point back to the hospital and you immediately lose trust and value in the health care service provider that you were going to.

00;05;11;18 - 00;05;21;13
Johnathen Inskeep
It's just devastating. And then a lot of people, it's like, I don't really have any problems, but I don't want any problems that I've had shared with anybody. So it really just leaves you vulnerable.

00;05;21;15 - 00;05;42;15
John Riggi
Just think about it from the patient perspective. As you said, you're getting these calls. And of course, the first thing that patients are going to do is call the hospital. Now the CEO is getting calls. . . . word that these patients are being directly extorted. Imagine again the pressure on the hospitals. Nobody wants to pay ransom. And again, of course, we at the AHA strongly discourage the payment of ransom.

00;05;42;15 - 00;06;06;07
John Riggi
It will only encourage these groups to continue to conduct these attacks and fund them for perhaps other, more serious crimes as well. But you know what I was confused about, I should say, wondering about in this latest, highly publicized case when they were contacting patients directly for demanding a ransom payment from them, they were only asking $50 each.

00;06;06;10 - 00;06;08;13
John Riggi
I don't get that. That's a lot of work.

00;06;08;14 - 00;06;28;01
Jake Milstein
You know, it's super interesting. It's super interesting. And, you know, I've seen a debate and actually been part of a debate on this. So folks know what this is. And I might have the exact figures wrong here, but basically what the criminals said was pay us $3 and we'll let you know if we have your records. You can see your record for $3.

00;06;28;01 - 00;06;50;23
Jake Milstein
And if you want us not to expose your record publicly, then it's $50. And so some people have said that really this is just a pressure tactic that I personally think that that is more advanced than a pressure tactic. And I actually think that the bad guy - this is just a new revenue stream for that. It is the what is the triple extortion?

00;06;50;23 - 00;07;09;13
Jake Milstein
The quadruple extortion. I think you know, this is the you know, we're going to tier your payments. I actually think it's a revenue stream because, you know, you know, criminals are you know, they're good at math. We know this. You know, let's say you have what, 100,000 patients and everyone pays you $50,000. I mean, you know, it's real money.

0;07;09;15 - 00;07;33;00
John Riggi
Right? And, you know, as I'm thinking this through, ransomware as a service has proliferated dramatically the past couple of years. And people are assuming, wow, if they're demanding millions from the hospital victim, why would they go after patients for $50? Well, maybe this is a separate department within the ransomware as a service. Said, you guys can have the patient aspect of this.

00;07;33;03 - 00;07;54;12
John Riggi
There's others we know that are making money off stolen credentials. So we have the initial access brokers. This is truly a very efficient underground economy all around ransomware where there are multiple components making money off different aspects of the attack. So this is my theory only there's probably some groups said, hey, whatever you can collect from the patients you keep.

00;07;54;15 - 00;07;58;11
John Riggi
And that helps apply pressure to the victim organization as well.

00;07;58;16 - 00;08;32;17
Jake Milstein
Yeah. I mean, rewinding back to that Texas attack on the school district. There was no demand for money from the parents. That was strictly a hey, call the school district and, you know, get them to give us $5 million or whatever the ransom was. This new thing is different. Now, I will also say there's another case in, I believe, the Los Angeles area - plastic surgeon, bad guys got the pictures and both extorted the plastic surgery clinic and demanded $500 per patient from the patients.

00;08;32;19 - 00;08;47;01
Jake Milstein
Now, I will say that is an actual moneymaking scheme. And, John, if you're right, you know, what we're looking at here is these criminal enterprises, and they are enterprises are now developing a B2B wing and a B2C wing. Like this is ridiculous. But that's what we're starting to see here.

00;08;47;03 - 00;09;07;26
Johnathen Inskeep
Yeah. The other thing I would say, too, is when you have a victim called like that, what are they preying upon? The reaction of the victim, right? So as the victim...oh my gosh, they have my information. I'm going to pay the $3. Well, that's a great way for that victim to be victimized again, because you put in through their paywall your information to be able to pay that.

00;09;07;26 - 00;09;22;05
Johnathen Inskeep
Now they have your financial information to take advantage of your debit card, right? So a great way to snag the person once again, unfortunately, it's just a great way to prey upon a person, which is just unthinkable.

00;09;22;08 - 00;09;25;01
Jake Milstein
Are you saying the criminals don't accept cash, Johnathen?

00;09;25;04 - 00;09;29;10
Johnathen Inskeep
I've never got one to accept cash. I would try to get him to do monopoly money once, but he told me no.

00;09;29;12 - 00;09;30;05
Jake Milstein

00;09;30;08 - 00;09;58;00
John Riggi
Wire transfers? No, that's no good. Digital currency? I recently made a provocative comment on social media, in a sense. And I said that digital currency is the root of all cybercrime. And ultimately, if it wasn't for crypto digital currency, it would be much more difficult for bad guys to conceal, transfer, anonymize the proceeds of crime and certainly would take a massive reduction.

00;09;58;00 - 00;10;04;12
Jake Milstein
Yeah. I mean, I think that that is definitely true. I'm not sure I agree that it's the root of it.

00;10;04;12 - 00;10;05;07
John Riggi
They're meant to be thought-provoking.

00;10;05;07 - 00;10;25;20
Jake Milstein
I understand. You know what, I don't know if it's the root of it, but I do think that it brings up an interesting question for folks like it is. I understand deeply that the AHA tells people not to pay a ransom. I don't think people should pay a ransom. Some organizations make the business decision to pay the ransom.

00;10;25;23 - 00;10;47;14
Jake Milstein
And one of the things that folks need to do in building an incident response plan is to come up with, are we going to pay the ransom? Under what duress would we pay the ransom? Would we never pay the ransom? And I will say, if you come to the possibility that you might pay the ransom, think about how you're going to do that before you're in this situation.

00;10;47;17 - 00;11;02;23
Jake Milstein
If you're going to have to buy Bitcoin, how are you going to do that? If you're going to use a firm, how are you going to do that? Again, do not think anybody should pay the ransom. But this is all part of it. I will tell folks, I was in a fascinating tabletop with this guy, John Riggi, who's joining me on this podcast.

00;11;02;25 - 00;11;18;12
Jake Milstein
There was, hospital exec and the hospital exec said, I'm never going to pay the ransom. I'm never going to pay the ransom. John, I don't know if you remember this. And John got to, you know, all your systems are shut down. No, I'm not going to pay the ransom. You're on divert. I'm not going to pay the ransom. 00;11;18;16 - 00;11;26;08
Jake Milstein
And then John said, the criminals have started calling your patients. And this hospital exec said, okay, I'm paying the ransom.

00;11;26;10 - 00;11;46;04
John Riggi
Exactly right. There is a boundary. They know what the pressure limits are to extort these payments. These are equivalent of violent crime extortions. So you know my background, 30 years in the FBI - dealt with a lot of bad guys, including Russian organized crime bad guys, and terrorists as well. They know what the pressure points are, apply pressure to get whatever their objective is.

00;11;46;04 - 00;12;08;10
John Riggi
They claim these are financially motivated crimes, the bad guys, but really financially motivated, under threat of harm to patients, under threat of harm to patients again is why we always say these are threat to life crimes. There is a whole network now. Again, I said a whole industry around how do we creatively find ways to extort money out of the victims?

00;12;08;10 - 00;12;37;03
John Riggi
We extort the patients. We also have data leak sites that if the organization, the victim organization has not reported the attack publicly, the ransomware guys publicize it on their public web leak sites, notifying the government. So they have all types of issues there. Again, trying to maximize pressure on the victim to pay. Again, we discourage payment. We know that ultimately, even the FBI says this is a business decision.

00;12;37;06 - 00;13;01;11
John Riggi
And if patient safety is at risk, that is a consideration of whether to pay or not. Now, the best way is you talked about being prepared. Cyber insurance companies now actually generally come with their cyber policy methodology is to pay the ransom in digital currency. They actually have ransomware negotiators. There's a whole industry on the good side that's developed around ransomware.

00;13;01;14 - 00;13;22;12
John Riggi
So all these things have to be thought out. But ultimately we say, look, just don't get yourself into that position if at all possible. Offline secure backups that are immutable, that you can use to restore, know where your data is. But ultimately, if your data is encrypted, the bad guys can't use it. Even if they get to it, they can't use it.

00;13;22;14 - 00;13;48;28
John Riggi
Quite frankly, I think that there is not enough attention being focused on data mapping and encrypting the data. All these layers of technologies, millions and millions we spend are around protecting data, ultimately to protect patients. So let's start at the bullseye. Let's encrypt the data at rest and in transit. Even the government says if the bad guys get to your data and it's not readable, you don't even have to report it.

00;13;49;00 - 00;14;10;15
John Riggi
So again, let's start with some of the fundamentals and the basics. So speaking of vulnerabilities right? Which lead to these attacks for both of you. So are there common vulnerabilities in hospital systems that you see that cybercriminals, especially ransomware groups, are most frequently exploiting? Maybe Johnathen, you could take that.

00;14;10;18 - 00;14;31;04
Johnathen Inskeep
I think they take advantage of obviously the patient care aspect, right? But what they're finding is a lot of these real hospitals and stuff like that, maybe lack a little bit of direction and don't have the securities in place to be able to handle those type of attacks. And then what happens is that can either come in through a third party.

00;14;31;06 - 00;14;46;09
Johnathen Inskeep
There's a lot of risks that's there. There's a lot on the plate for the hospital, and it just puts them as a prime target, right? They've got all the medical record information there on the patient. They know they can hit a bunch of people all at once. And so it's actually kind of a scary scenario. You're just you were talking about targets.

00;14;46;09 - 00;15;00;25
Johnathen Inskeep
Hospitals are the prime target. And so to try and find a way to curb that, I agree with the encryption process. I also think that you should be following a security framework to help narrow that gap, to be able to identify risk. Yeah. Ultimately you're always going to be a target for the bad guys to hit.

00;15;00;28 - 00;15;23;21
Jake Milstein
And I think there's a basic unfairness here. There's a basic unfairness in that you can do everything that you should do to build up your defenses, and yet the bad guys only need to be able to get in one way. And when you look at that and you look at how they're getting in, it used to be the number one way bad guys got into hospitals was through email.

00;15;23;23 - 00;15;58;01
Jake Milstein
That's no longer the case. So when you look at the HHS data, you know, the number one way that they're getting in is through vulnerabilities and through third parties. What's a vulnerability? So a vulnerability is every time Chrome tells you to update or your iPhone tells you to update or whatever, because there's a vulnerability. If you look at all of the devices, if you look at all of the software a hospital is using, all of them, there are vulnerabilities that need to be patched, and those patches need to be treated as urgent incidents so that bad guys can't get in.

00;15;58;03 - 00;16;21;13
Johnathen Inskeep
And I would add to that, the other thing that's really makes it difficult is you to patch your home computer pretty easy-peasy, right? For some of these hospital systems, for them to be able to implement a patch, whether it's an EHR patch or even just a simple Microsoft patch, it takes a lot of coordination to make sure that that patch doesn't have a profound effect on other operating systems, right?

00;16;21;13 - 00;16;39;13
Johnathen Inskeep
So there's a lot of times that those patching processes take proper planning, like how do we have time to be able to have downtime for the network to be able to restart and implement the patch, do a little bit of testing. And so when they drop, unfortunately, we can't just immediately go run and patch it and come up all good, right?

00;16;39;20 - 00;16;44;11
Johnathen Inskeep
There's a little pre-planning that has to take place which leaves you exposed.

00;16;44;13 - 00;17;16;09
Jake Milstein
And you know we mentioned third party. So I want to break third party vulnerabilities into two buckets. Bucket number one is third party is holding patient data or employee data. And bad guys get it by getting into a third party system. And that's the data theft. The other is the third party has a door into the hospital network, and then the bad guy uses that door to get into the hospital network, and then is able to launch a ransomware attack on the hospital network.

00;17;16;09 - 00;17;22;02
Jake Milstein
Those are two different kinds of third party vulnerabilities, and both are getting bigger and bigger.

00;17;22;03 - 00;17;52;21
John Riggi
Yeah, I agree, and is actually even a couple more. So not only do they hold the data or they are the electronic pathway in because how does that all that data move through electronic transmission, but also that the third party themselves maybe become victim of a ransomware attack, which then disrupts hospital operations? You have some mission critical or as I often say, life critical third party that immediate patient care depends on - is then struck with ransomware.

00;17;52;21 - 00;18;14;21
John Riggi
And the bad guys are strategic and intentional. They know if we hit this particular third party, it will disrupt care in 100 health systems, placing massive pressure on that third party to pay tens of millions of dollars in ransom, tens of millions of dollars in ransom. So and then there's the other third party risk of their technology risk, third party technology that has vulnerabilities in it.

00;18;14;21 - 00;18;21;19
John Riggi
Right? We don't write our own operating system code very often I would assume. We don't build our own medical devices. We rely on third parties.

00;18;21;21 - 00;18;41;05
Johnathen Inskeep
Yeah, absolutely. I can't remember the last time I broke down the code to build something, right? So we have all these dependencies. And I think one of the biggest things centered around that is proper risk identification, right? If you take a third party on for operational purposes, how much do you know about either of that product? Where was that product made, manufactured?

00;18;41;05 - 00;19;01;02
Johnathen Inskeep
What's the risk of it coming into your environment and third parties you work with? Like what's the obligation? How strong is your business associate agreement with that third party vendor? Did you identify things that are related to risk in your environment that you're talking about in your business social agreement? Because I tell you, if you don't have it listed, they're not going to be held accountable for it.

00;19;01;05 - 00;19;23;02
John Riggi
Quite frankly. You know, we don't want to alarm folks too much here, but really it's third party risk management and fourth party. So, who are the subcontractors for those third parties? That should be part of the evaluation. Where are they based? Are they based in the United States or overseas? China's ofering a lot of good deals these days to get into our health care sector.

00;19;23;09 - 00;19;26;26
John Riggi
Unbelievably good deals, related to the Chinese government.

00;19;26;26 - 00;19;28;24
Jake Milstein
We saying that deals are too good?

00;19;28;27 - 00;19;53;23
John Riggi
They're too good to be true, right? As we always say. So take a close look at that. What type of technology are they using? Is that technology vulnerable? Third and fourth party risks? Some of it you can control, some of it you can't. But that's where we have to be ready with that incident response plan that not only takes into account if you are the direct victim, but what about if our mission critical third parties are attacked?

00;19;53;28 - 00;20;05;14
John Riggi
How does that disrupt our operations, disrupt and delay patient care, risking patient safety. And the IT department has no control. Right, Johnathen, your third party gets hit. What do you what can you do about that?

00;20;05;21 - 00;20;23;26
Johnathen Inskeep
No control because you have to function. I think one of the most interesting things was this like our EMR vendor that we had - American company, right? However, when we went to do updates at night with the HR vendor, they were people from India that we worked with. And what was interesting to us is we had a geo blocked on India.

00;20;23;29 - 00;20;41;28
Johnathen Inskeep
So they had to call me and say, hey, we can't connect to your system. Can you make an allowance on your firewall? And that wasn't a risk that we thought we would run into because we're working with the American company that's here in America, and they outsourced their technical deployment out to India. And it was just this astonishing.

0;20;41;28 - 00;20;47;26
Johnathen Inskeep
Like we didn't factor that in when we committed to the HR program. And it's things that hindsight we should have looked at.

00;20;47;27 - 00;20;53;03
John Riggi
Right. And of course, the time you discover that is in the midst of a crisis.

00;20;53;05 - 00;20;54;05
Johnathen Inskeep
Absolutely.

00;20;54;07 - 00;21;26;15
John Riggi
You know, I do a lot of media. Talk to a lot of reporters. I explained to them in these terms, hey, these are foreign bad guys being sheltered by hostile nation-states, attacking us, putting us at risk. They're very sympathetic. They understand and generally do want us want to help by promoting good, accurate information. So just as when we face the threat of terrorism, the media was very helpful to distribute alerts to really show what the impact of these threats are and help folks prevent attacks.

00;21;26;17 - 00;21;54;17
John Riggi
Thank you both, Johnathen and Jake, for sharing your thoughts and insights and joining this podcast with us today. For AHA members, for our listeners, if you would like to learn more about AHA's cybersecurity programs, please visit aha.org/cybersecurity. This is been John Riggi, your national advisor for Cybersecurity and Risk.

00;21;54;20 - 00;21;57;23
John Riggi
Stay safe.

00;21;57;25 - 00;22;06;07
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;18 - 00;00;23;07
Tom Haederle
Every rural care provider in the United States can attest that finding, hiring and retaining clinicians across just about any specialty is getting harder and harder. In south central Washington state. Kittitas Valley Health Care, KVH, the only provider offering comprehensive OB-GYN services for many miles around, was suddenly faced with a huge problem. Within the space of about a year

00;00;23;08 - 00;00;37;27
Tom Haederle
its three full time OB-GYN specialists all decided to leave.

00;00;38;00 - 00;01;05;12
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Prior to 2022, KVH was delivering between 300 and 350 babies each year. Its six bed labor and delivery unit was the most in-demand service the hospital offered. In this podcast, we learn from the hospital's CEO how KVH kept its balance and its promise to area residents to preserve critical obstetric services

00;01;05;19 - 00;01;09;27
Tom Haederle
in the wake of the departure of several highly experienced clinicians.

00;01;09;29 - 00;01;22;18
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Julie Petersen, CEO, Kittitas Valley Health Care and Public Hospital District. Good afternoon. Julie.

00;01;22;20 - 00;01;23;20
Julie Petersen
Hello.

00;01;23;23 - 00;01;56;18
John Supplitt
For our listeners, Kittitas County Public Hospital District number one, also known as Kittitas Valley Health Care, provides care to Kittitas County and surrounding areas in central Washington state. KVH includes a 25-bed critical access hospital and provides care through clinics and specialty services in upper and lower Kittitas County. Julie, we're here to discuss how KVH has responded to a crisis to ensure continued access to obstetrical care in Kittitas County, Washington.

00;01;56;20 - 00;02;00;10
John Supplitt
How essential is obstetrics to your community?

00;02;00;12 - 00;02;22;10
Julie Petersen
We know from our latest Community Health Needs Assessment that admissions for women of childbearing age is our number one admission to our hospital. So this will include delivery as well as complications from deliveries and prepartum and postpartum issues. So it's not just an essential, it's a core service for our community.

00;02;22;12 - 00;02;39;03
John Supplitt
And I think I want to pull a thread on that because it's remarkable when I looked at your community health assessment and improvement plan, to see these conditions as being the highest source of admissions to the hospital for women of all childbearing ages, including teenagers.

00;02;39;03 - 00;03;03;04
Julie Petersen
Correct. And we staff a dedicated labor and delivery unit, a six-bed labor and delivery unit. We are a 25-bed critical access hospital. So our general medicine CCU population includes a number of different DRGs and conditions. But again, the number one major diagnostic classification that we have is those moms prepartum postpartum and the deliveries themselves.

00;03;03;04 - 00;03;25;28
Julie Petersen
And we deliver about 300 to 350 babies a year in Kittitas County. We have about 80% of the of the market of deliveries. And we're very, very careful in how we screen our moms. We know our limitations with our labor and delivery program. But again, that's 300 to 350 babies a year that rely on us to deliver them in Kittitas County.

00;03;25;29 - 00;03;27;24
Julie Petersen
We are the only hospital in the county.

00;03;28;00 - 00;03;44;15
John Supplitt
And that's a remarkable number. And I think we need to really get a sense of where you are relative to the other providers in your area with respect to location. You're in south central Washington to the south of you. The nearest city is Yakima.

00;03;44;17 - 00;04;05;00
Julie Petersen
That's correct. So any direction you want to go to deliver outside of Kittitas County, you're going to have to travel over a mountain range. You travel to Wenatchee, which is a mountain pass. That's about 40 miles. You can travel to Yakima, 35-40 miles over a mountain range or into the Seattle metropolitan area of the Cascades.

00;04;05;02 - 00;04;12;17
John Supplitt
And so recently, you've experienced significant disruption, disruption in your OB-GYN services. Tell us what happened.

00;04;12;20 - 00;04;43;23
Julie Petersen
Prior to 2022, we have worked with a pool of community providers, including those sole practitioners who retired in 2022. We also had an FQHC in our community that participated in our call and delivery program. And due to changes in the residency program and then just a tight OB market, that program has slimmed down in our community. But we have employed three OB-GYNs, and our community has been kind of the core of our model.

00;04;43;26 - 00;04;59;00
Julie Petersen
But in 2022, all three of those providers gave us notice that they would be leaving. Two of them continue to live in our community, but they travel to metropolitan areas to participate in labor programs in the large hospitals.

00;04;59;02 - 00;05;13;20
John Supplitt
Well, and again, I have to pull a thread on this because your model through 2022 was an employed service through your own OB-GYNs, which is remarkable to think that you were able to recruit them into the first place and that they were committed to the community for so long a period of time.

00;05;13;28 - 00;05;40;10
Julie Petersen
Right. And that that level of commitment, that market of being able to employ an OB-GYN who is responsible for their patients, 24/7 who disrupts their clinic life to go to the hospital to deliver a baby on the middle of a Wednesday afternoon. That market is harder and harder to draw to, and that is absolutely what we were trying to maintain in KVH, again with the participation of some great partners

00;05;40;10 - 00;05;47;29
Julie Petersen
in the FQHC and some private practitioners. But within the span of about 14 months, that entire model just came up hard on us.

00;05;48;03 - 00;05;55;19
John Supplitt
So you get punched in the gut as you see this attrition in your employed model of care. How did you respond to this crisis?

00;05;55;21 - 00;06;22;12
Julie Petersen
Well, the governing board, we are an elected board of five commissioners in Kittitas Valley. And they came out of the gate assuring the community and assuring our staff that we were going to remain in the OB business. So my charge was to make it happen. We'd already been recruiting to replace the traditional OB-GYN providers that we'd had in the past and we were not having very much success.

00;06;22;14 - 00;06;45;14
Julie Petersen
We did come across a family practice OB who has surgically trained, who's a key component of our program going forward. But after about 12 to 14 months of looking to backfill our OB-GYNs, we had no choice but to look outside for an outsource service, and we found a partner in OB hospitalist group or OBHG.

00;06;45;16 - 00;07;11;29
Julie Petersen
So again, I think the first thing we did was make the commitment from the governing board on down that we were going to continue to deliver babies in Kittitas County, and that's key, because one place where we're particularly strong is in our nursing program. We have an amazing group of labor and delivery, specialty trained nurses who have stuck through us, with us through this entire sort of meltdown in OB.

00;07;11;29 - 00;07;17;11
Julie Petersen
And the last thing we wanted to do was make ourselves vulnerable to losing those nurses.

00;07;17;13 - 00;07;26;23
John Supplitt
Well, and I'm going to share a couple of observations. First and foremost, this is a public district hospital and that the board is committed to delivering babies to this community.

00;07;26;27 - 00;07;28;09
Julie Petersen
That's absolutely correct.

00;07;28;09 - 00;07;31;11
John Supplitt
And that's at the core of your mission.

00;07;31;11 - 00;08;01;28
Julie Petersen
Right. That was never a question. And I think the way we see this is, again, our folks have been rigorous and determining who should deliver at KVH. We don't do high risk deliveries. And when you take 300 to 350 moms who can deliver in a safe hospital environment and put them on the road over mountain passes or 35-40 miles stretches, you take low risk, comfortable births, and you turn them into high risk births. That was not acceptable at my board.

00;08;02;00 - 00;08;25;25
John Supplitt
And then the other observation is, as we see hospitals drop obstetric services from their service components, I again reflect on the fact that as a public district hospital, your commitment to the community is at the core of what it is that you do. And in this particular, you're willing to take on this loss- leader in order to make sure that there's access to safe care to the women that live there.

00;08;25;27 - 00;08;49;29
Julie Petersen
And we see this service line also. At the core of this service line is labor and delivery and obstetrics. And that certainly is the biggest challenge in terms of continuing the service line. But it is bigger than that. We are a county of about 45,000 people, and we're a little bit unique in that we are growing as a sort of a long distance neighbor to the Seattle metropolitan area.

00;08;49;29 - 00;09;12;05
Julie Petersen
We are growing and we're holding our own in terms of age. So we're not aging the way some rural communities are. So long term, we need not only to be able to deliver our own babies, but we need to be able to take care of women generally in our community, the reproductive health needs of women, gynecological needs of women in our community are core to this as well.

00;09;12;07 - 00;09;25;28
Julie Petersen
And if you can't attract OB-GYNs, if you can't attract the nurses who care for women in the clinics in the hospital, you're going to lose your ability to take care of women generally, and reproductive health specifically.

00;09;26;01 - 00;09;43;00
John Supplitt
Julie, let's talk about the selection of OB hospital group as your agency to service this labor model. There had to be some research that went into that. There had to be some board buy-in and acceptance of this. Tell us a little bit about that process and how it went.

00;09;43;02 - 00;10;08;02
Julie Petersen
During the pandemic and initiating our research, one of the things that we learned is in a very short period of time, many, many hospitals had transitioned to a labor site model. And while it's largely an urban/suburban phenomenon, we saw some of it moving into the rural communities as well. So we looked for somebody who had experience in rural communities. And rural is different than urban,

00;10;08;02 - 00;10;33;24
Julie Petersen
they needed to be able to or willing. They needed to attract candidates who would work in a clinic setting, who would do general GYN surgery, and to that time as a laborist as well. So we needed to partner with someone who would be flexible, who would include our own dedicated staff, our family practice OB that I mentioned, our certified nurse midwife.

00;10;33;26 - 00;10;58;09
Julie Petersen
We had folks who we knew were really dedicated to our community, and we needed a partner who would build around them. So we worked with GBHG. They basically said, sat down with us and said, let's build some schedules. Let's see how we can make this work. And we settled on a three week a month rotation. When you were on call to deliver babies, that's all you do.

00;10;58;11 - 00;11;21;23
Julie Petersen
So again, delivering maybe a baby a day, that's not overly burdensome. It is a 24 hour commitment. But for seven days that's what you do. The next week you get off, you return to clinic work and just clinic work for the following two weeks. And that seems to have been an attractive model, not just for our own delivering physicians, but for OBGH as well

00;11;21;23 - 00;11;25;00
Julie Petersen
and they're having some success in recruiting to that position.

00;11;25;05 - 00;11;39;07
John Supplitt
Which is excellent news and I'm sure a relief to you. So this is how you're going to put this model into practice. How has the community received the message, or do they even understand the message that you're changing the model? Is it relevant to them?

00;11;39;09 - 00;12;03;08
Julie Petersen
You know, you lead with the fact that except in a rural community, people don't expect the OB they see in their clinic to deliver their baby in very many facilities anymore. So this is not new to people. It's new to Kittitas and to our population, but they were very much aware of it. And if they delivered somewhere else, that's probably the model that they had seen.

00;12;03;11 - 00;12;20;07
Julie Petersen
The thing we had to say over and over again is that we are committed to this. It's not going to be easy. We're not going to be able to do it overnight. But we have never been on divert for deliveries. So whatever it took to pull that together and keep that service intact, our board has been willing to make that commitment and do that.

00;12;20;07 - 00;12;26;03
Julie Petersen
And frankly, I think the community has come to believe us. They've seen how we've struggled, but they know we're in it.

00;12;26;06 - 00;12;38;17
John Supplitt
Nevertheless, Julie, it's a radical change in the way in which you've delivered OB in the past. I'm curious to know, given the importance of the nursing component, how has your nursing service responded to the change?

00;12;38;20 - 00;13;02;27
Julie Petersen
Labor and delivery nurses are the number one reason that we're seeing rural communities go out of the OB business. So while we have struggled with an OB-GYN component with first assist, of course have to have anesthesia available. You have to have someone there to take care of the baby as well. You have to have pediatricians or acute newborn providers and a cesarean section to take care of the babies.

00;13;02;27 - 00;13;27;02
Julie Petersen
So it takes a team. But our nurses are the bedrock of that. And we talk about labor and delivery. Eleven hours of labor and delivery is all about the nurse. The doc walks in and is there for a short period of time. Our nurses are dedicated. They have a lot of longevity, and they are just used to doing whatever it takes to get the job done, and that's what they've done for the last 15 months.

00;13;27;05 - 00;13;51;26
John Supplitt
So all these things considered, given the changes that you're planning - two questions. The first is what's the timeline for implementation? You really started this process back in 2022-2023. You've moved forward for the research. You made the decision to go to be with OB hospitalist Group in October of 2023. What's the timeline now for looking forward in terms of making this permanent?

00;13;51;28 - 00;14;23;06
Julie Petersen
We believe we will be fully staffed between our own providers and OBGH in July of this year. So it has been a long haul. We've been on the pediatric side of it. We've been building our acute newborn so that that's a very reliable group now. And anesthesia as well. So we feel like once we have weathered the storm of a lot of locums and short term locums, and we get our OBHG hospitalist on board, our own folks on board, we're going to be ready to go.

00;14;23;06 - 00;14;53;12
Julie Petersen
So July, August of this year. And again, a component of this and one of the ways that we make this affordable - and labor and delivery has always been a loss leader - but one of the ways we make this affordable is through this OB-GYN model is we do have built in GYN surgical time. So we're able now or we will be able to take care of more of the general gynecological needs of the women in our community than we've ever been able to take care of before.

00;14;53;15 - 00;15;05;17
John Supplitt
Well, and I think that that's the question, and that'll be the last question I ask. And that's the one that everybody wants to hear, is, how are you going to pay for this? How are you going to meet the expenses to make sure that this service remains viable moving forward?

00;15;05;20 - 00;15;34;24
Julie Petersen
So every schedule we've put together also includes that GYN surgery day. So our OB-GYN will be doing more surgery than are the ones that have been working 24 hours a day to deliver babies were willing to do. So GYN services will continue to increase. This, frankly, is a service that we have always look to our 340B savings to help support and like everyone else who delivers babies, we lose money on it

00;15;34;24 - 00;15;46;20
Julie Petersen
so we made a direct connection to those 340 B savings. So we keep a close eye on that as well. It is not going to be easy financially. We will struggle because of this. But again, we're committed.

00;15;46;22 - 00;16;05;27
John Supplitt
Well. And you raised some very important points is that none of these programs exist without the other. And 340B is essential to rural community hospitals across the country. It is the margin for many critical access hospitals and what you're suggesting, it's going to be pretty much the margin for you to be able to continue this OB service.

00;16;06;00 - 00;16;33;26
John Supplitt
I think I really, on behalf of all of our listeners, want to thank you and your board for the commitment to making sure that OB is available to the residents of your community. That they're not put at risk for unsafe deliveries, unhealthy situations, becoming unsafe because they have to cross a mountain pass. I think it's a huge commitment on behalf of your community and your leadership in making this happen to really implementing this practice and making it come so quickly

00;16;34;00 - 00;16;37;01
John Supplitt
given the crisis that you were confronted with just a few months ago.

00;16;37;07 - 00;16;38;25
Julie Petersen
Well, thank you. It's a privilege.

00;16;38;28 - 00;17;09;02
John Supplitt
I want to thank my guests. Julie Peterson, CEO of Kittitas Valley Health in Ellensburg, Washington, for sharing her important story and providing essential health services and reimagining OB to ensure continued care for the residents of Kittitas County. Your commitment is inspiring, and we'll be watching closely as you grow and evolve under this new model of care. I wish you every success in your effort and hope to learn more about how we can learn from your experience.

00;17;09;04 - 00;17;19;01
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;17;19;04 - 00;17;27;15
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;17 - 00;00;38;18
Tom Haederle
Some 57 million rural Americans depend on their hospital as an important source of care, as well as a critical component of their area's economic and social fabric. But many rural care providers have faced and continue to face a rocky road ahead. Attracting and retaining workers. Financial stresses. Dealing with complicated and sometimes conflicting regulations. These are among the factors that can jeopardize the ability of rural hospitals to provide patient access to care.

00;00;38;20 - 00;01;13;07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. AHA has made improving access to rural health a top priority. Our 2024 Advocacy Agenda for lawmakers and policy recommendations to government agencies lays out the groundwork for needed change to improve the system for patients. In this podcast, two AHA experts drill down into some of the specific steps needed to help essential rural health care providers stay solvent, healthy, and able to serve the patients and communities who depend on them.

00;01;13;09 - 00;01;20;19
Tom Haederle
The discussion took place at the 2024 AHA Rural Health Care Leadership Conference in Orlando, Florida.

00;01;20;22 - 00;01;49;08
Lisa Kidder
Good day. I'm Lisa Kidder, senior vice president, AHA advocacy and political affairs. I am joined today by my two colleagues, Travis Robey, vice president of political affairs, and Shannon Wu, senior associate director, AHA payment policy, two of the experts on rural health care. Welcome, Shannon. Welcome, Travis. We all know rural hospitals continue to experience ongoing challenges that jeopardize the ability to provide local access to care and essential services to their patients and community.

00;01;49;11 - 00;02;19;17
Lisa Kidder
Examples include workforce shortages, financial instability, overwhelming regulatory burden, just to name a few. AHA continues to work with Congress and the administration to enact policies or sometimes to stop policies to support these rural hospitals. Recently, we announced our AHA Rural Advocacy Agenda for 2024. I am going to talk to Travis and Shannon about the advocacy agenda and share with you some of the details as we drill down a little bit.

00;02;19;20 - 00;02;39;04
Lisa Kidder
Travis, let's start with you. As AHA continues to work with Congress and the administration to support these rural hospitals. We're also looking to support a public policy environment that will protect access to care, innovation and invest resources in new rural communities. Could you talk about those five areas, please?

00;02;39;07 - 00;03;02;11
Travis Robey
Absolutely. Our first priority in our updated rural advocacy agenda is commercial insurer accountability. It continues to be an issue that we hear as a top tier issue of concern for our members. Second is supporting flexible payment options. Third is ensuring fair and adequate reimbursement. Fourth is bolstering the workforce. And fifth is protecting the 340B program.

00;03;02;14 - 00;03;19;15
Lisa Kidder
Great. Thanks. I will dig into some of those issues here in just a minute. Shannon, as Travis mentioned, the number one he first mentioned and maybe even number one on our priority list this year is commercial insurer accountability. Can you talk a little bit about what's been happening with the administration and some of the actions they've taken to address this issue?

00;03;19;17 - 00;03;42;06
Shannon Wu
Sure. We've already seen some moves in the right direction from the administration, from last year and the beginning of this year. So first, we are carefully monitoring compliance and the recent Medicare Advantage rules that were finalized last year, which went into effect last month in January. Many of these rules hold plans accountable for covering services and for their marketing tactics, among other requirements.

00;03;42;09 - 00;04;05;10
Shannon Wu
So we're keeping a close eye on how this Medicare Advantage plans are complying with those rules for the upcoming year. Second, the administration also finalized just last month in January again, prior authorization rules that the AHA advocated heavily on. These will go into effect in the next few years and are really aimed at streamlining and reducing burden associated with prior authorization and at promoting greater transparency.

00;04;05;12 - 00;04;14;21
Shannon Wu
Of course, our work here is not done, and we continue to advocate for ways to reduce administrative burden and help our rural hospitals navigate through the changing Medicare Advantage landscape.

00;04;14;24 - 00;04;30;21
Lisa Kidder
Thanks, Shannon. It sounds like lots of good work is being done. Travis, let's talk about another issue that has getting a lot of attention in Washington, D.C. right now from both sides, both those who are for it and against it. Can you tell us about site neutral and what is happening right now in Congress on the issue?

00;04;30;24 - 00;05;02;18
Travis Robey
Absolutely. Hospitals and health systems play a critical role in preserving access to care for patients and communities throughout rural America. They've increasingly stepped up to fill the voids in care by reinvesting through access points like hospital outpatient departments. These sites of care are essential services in so many rural and low income communities across the country. Our emphasis right now is trying to push back on congressional efforts to impose site neutral payments, particularly for drug administration.

00;05;02;19 - 00;05;26;21
Travis Robey
But their longer term vision is far more expansive than that. And the impact on rural communities is particularly acute. We've recently put out data that shows that disproportionately rural patients access care at hospital outpatient departments. And we want to ensure that that access continues going forward by opposing the site neutral cuts.

00;05;26;23 - 00;05;33;17
Lisa Kidder
And, Travis, I hate to put people on the spot, but I'll put you on the spot. What do you think the chances are that Congress takes action this year on the issue?

00;05;33;19 - 00;05;59;18
Travis Robey
Well, right now we've got, in the short term, the March 1st and March 8th government funding deadlines that put us at risk on these issues. The hope is that we can stave off any pending cuts in that government funding package that's going to move in the next month, but then we'll still have the lame duck session of Congress in November and December, where this will be a top tier issue.

00;05;59;21 - 00;06;20;13
Travis Robey
So we need to make sure that our rural members and all of hospital leaders across the country are engaging with their legislators to make sure that the message gets delivered, that the current payment model is essential to maintain access to care, particularly given the financially vulnerable position of so many rural and safety net hospitals.

00;06;20;16 - 00;06;36;19
Lisa Kidder
Great. So that sounds like a call to action as well as an update. The next issue I know is one that really hospitals and hospitals really across the country are dealing with that definitely peaked during Covid. But can you talk about workforce challenges? So Travis, I'll send it to you. But then, Shannon, you may have thoughts as well of some of the issues you've worked on.

00;06;36;19 - 00;06;39;10
Lisa Kidder
So, Travis, why don't you go first and then you can turn it over?

00;06;39;12 - 00;07;06;10
Travis Robey
Yeah. This is a key area where there is the potential for possible bipartisan support over the coming months. The National Health Service Corps is up for reauthorization. We're also advocating for an expansion of graduate medical education residency slots. Over the last several years, we've seen investments in more GME slots after nearly a couple of decades where there had been a freeze on those slots.

00;07;06;12 - 00;07;33;21
Travis Robey
But there are also rural specific proposals, like the extending the Conrad state 30 program, which allows J-1 visa waivers for physicians who train in the U.S. to be able to stay here if they practice in an underserved or rural community. So there are a variety of key workforce provisions that are specifically focused on rural, but I want to highlight one additional area: the SAVE Act. That's focused on workplace violence,

00;07;33;23 - 00;07;58;17
Travis Robey
such a key issue for employees and administrators at hospitals to take this issue head on. We just had a very successful - almost 100 congressional staffers attend a briefing on this issue that really, I think, drove home to congressional staff the importance of this issue, and we're looking to make progress on that over the coming months as well. And that's a bipartisan piece of legislation in the House and the Senate.

00;07;58;24 - 00;08;35;20
Shannon Wu
Great. Well, on the regulatory front, we've been really focused on the proposed nurse staffing minimum rules that were released by the Centers for Medicare & Medicaid Services last year. We strongly oppose these rules. So while we agree that staffing is an integral part of providing safe, high quality care, we believe that the proposed rules from last year really are an overly simplistic approach to a complex issue and that, if implemented, would have serious negative consequences not just for nursing homes but across the continuum, especially with ongoing workforce challenges that are preventing hospitals and rural hospitals especially, from discharging their patients in a timely manner to subacute or post-acute places.

00;08;35;23 - 00;08;43;26
Shannon Wu
So we are currently awaiting the final rule and in the meantime, have supported legislation that would prohibit the agency from finalizing those proposed requirements.

00;08;43;28 - 00;08;56;06
Lisa Kidder
Great, thanks. Going to turn to Travis again for an issue that has perennially gotten a lot of attention. And this is the 340B drug pricing program. Travis, I know that there's some interest in it right now on Capitol Hill. Can you bring us up to speed?

00;08;56;09 - 00;09;22;15
Travis Robey
Yes. The House of Representatives has had some hearings on this issue, trying to make changes that we think are problematic for the program. There's also been some legislation, a draft legislation put forward by some of the members of the Senate who have been champions of the 340B program. We're currently evaluating that to provide comments as they continue to refine that legislation moving forward.

00;09;22;18 - 00;09;43;28
Travis Robey
But I think the key message is that we want to make sure that all 340B hospitals are reaching out to their legislators to continue to explain the importance of the 340B program, how it ensures that you can stretch scarce federal resources further, and particularly for our rural members, how important it is to maintain access to care in your communities.

00;09;44;00 - 00;09;56;18
Lisa Kidder
Great,thanks. And just in the last couple of minutes, let me open it up to you. I know this is a question we sometimes ask our CEOs, but you know what's keeping you up at night? What's the unfinished business of rural health care that you'd like to see tackled? Shannon?

00;09;56;21 - 00;10;19;18
Shannon Wu
Well, I'll just continue on the 340B theme. And I want to mention here, obviously the AHA continues to oppose any efforts to undermine the 340B program, but in particular contract pharmacies. And we know how important that is for rural communities. So we know that there are still legal actions pending in the federal courts. And much of that action has moved to the states, which the AHA is very supportive and poised to help states in protecting access to contract pharmacy.

00;10;19;18 - 00;10;24;06
Shannon Wu
So that is something that we continue to monitor and continue to be engaged on for this year.

00;10;24;09 - 00;10;25;18
Lisa Kidder
Thanks, Travis. Anything from you?

00;10;25;25 - 00;10;46;01
Travis Robey
It really is site neutral for me. That's the issue that I think is front and center in Congress right now. There are certainly important provisions, like extending the Medicaid DSH cut moratorium that is essential for protecting the financial stability of the field. But I think right now, the number one threat to the hospital field are site neutral payment cuts.

00;10;46;03 - 00;11;02;07
Travis Robey
And that's what keeps me up at night, concerned that at a time of continued financial challenges for the field, that Congress might unwisely try to pass that legislation. So again, one last call to action on that. Please continue to reach out to your legislators on that issue.

00;11;02;10 - 00;11;14;20
Lisa Kidder
Great. Thank you so much to both of you. Lots of hard work being done. And again, thanks, Travis and Shannon for all your help. I am Lisa Kidder, and thanks for listening. This has been an AHA Advancing Health podcast.

00;11;14;22 - 00;11;23;02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;14 - 00;00;24;21
Tom Haederle
The reality of today's health care workforce is this demand outstrips supply. So every health care employer knows it's more important than ever to support their people and give them good reasons to stay not just surviving, but thriving.

00;00;24;23 - 00;00;53;05
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. For rural health care providers, especially, building and sustaining a strong and vibrant workforce that can meet the community's needs is paramount. In this podcast, recorded for the ages 2024 Rural Health Care Leadership Conference, we learn how the use of team steps and other tools has made a big difference for one rural system in Washington state, says today's guest.

00;00;53;13 - 00;00;57;08
Tom Haederle
The well-being of our team is foundational to everything we do.

00;00;57;10 - 00;01;19;05
Elisa Arespacochaga
Hi, I'm Elisa Arespacochaga vice president for clinical affairs and workforce, and today I'm joined by Brandie Manuel, chief patient safety and quality officer at Jefferson Healthcare in Port Townsend, Washington. We're talking about supporting the current health care workforce so that they can move from surviving to thriving. So, Brandie, let's start with tell me a little bit about yourself and your role at Jefferson.

00;01;19;08 - 00;01;39;26
Brandie Manuel
Thanks. I am a registered nurse. My background and I have been with Jefferson Healthcare for about 11 years. I started there as the Director of Patient Safety and Quality, and my role has evolved over time, and my interest in workforce development and supporting our workforce really goes back to wanting to provide the best patient outcomes for our community.

00;01;39;26 - 00;01;44;07
Brandie Manuel
And that's hard to do when you don't have an engaged team to take care of them.

00;01;44;09 - 00;02;12;06
Elisa Arespacochaga
Absolutely. So you're at a rural organization, but you still have to coordinate care across a huge area with a number of different partners across the continuum, some of which may be a boat ride away, some which may be several hours in a car away, all of which have an impact on the well-being of your team. So how do you coordinate some of that work to make sure that all the good you're doing for your own team continues to spread across that continuum?

00;02;12;09 - 00;02;36;00
Brandie Manuel
I think it has to do with how well we are collaborating with our external partners, as well as how well we're managing the work internally. So we've developed relationships with our paramedics. We have developed a community peer medicine program to look at fall prevention in older adults, and then we also work collaboratively with several of our partners, both across the water and even right next door.

00;02;36;02 - 00;03;02;02
Elisa Arespacochaga
That's great. So your organization, you've really understood that during the pandemic, you've really needed to help your own team thrive, because there weren't a lot of other people you could bring in. Tell me a little bit about how you really leveraged some of the work around teamwork. I know you were a big proponent of TeamSTEPPs and team training, which I am as well, but how did you leverage that work to really help your organization thrive?

00;03;02;05 - 00;03;23;07
Brandie Manuel
I think for us, we started TeamSTEPPs several years before the pandemic, which was fortunate because the tools and strategies really helped as we were navigating through that. So implementing and hardwiring things like huddles, briefs and debriefs, making sure that there's role clarity on the team and just really helping our teams use those tools to operate at the highest level that they could.

00;03;23;10 - 00;03;44;27
Brandie Manuel
Became critical during the pandemic, especially when you didn't know everybody that you were working with. We went from knowing every face in the hallway to having travelers, which we had never done before, and hiring new faces that were now covered by masks and no benefit of real social interaction outside of work. So having strong team skills and communication became pretty important.

00;03;45;00 - 00;04;09;15
Elisa Arespacochaga
And for those who don't know, TeamSTEPPs really is a rubric to take that team of experts and make them an expert team. And I love that definition, because it really is about how do you get everybody on the same page quickly? Tell me a little bit about what's up next in your plans and how you're going to sustain some of the improvements you've made in terms of really helping your teams gel and supporting them in their well-being?

00;04;09;17 - 00;04;28;21
Brandie Manuel
Yeah, we've just restarted TeamSTEPPS in person, so we did the updated curriculum, a new master trainer course in the fourth quarter. We have some new trainers coming in, and we're introducing the training as a hybrid option. So both kind of for people who've already taken it and want a refresher, but also for those who it's brand new for.

00;04;28;23 - 00;05;00;17
Brandie Manuel
And then looking at how we can embed those tools and strategies into our daily work even more than we have already, as well as our onboarding and sort of training that in addition to the work that we're doing to introduce those same tools and strategies to our medical directors and our medical staff leaders and head down the path of providing leadership tools and training for our physicians who are in leadership positions, maybe for the first time, and kind of introduce them to some of the same things we have done for our directors, managers and supervisors.

00;05;00;19 - 00;05;19;07
Elisa Arespacochaga
That's great. I know you've got a lot of different wellbeing sort of threads that are woven throughout. Can you just make that connection a little more? And I know you, you believe it. It's why you do this work. The connection between the well-being of your team and your your title. Chief patient safety and Quality Officer.

00;05;19;10 - 00;05;43;08
Brandie Manuel
The well-being of our teams really is foundational to everything we do. And for us, our mission really is to hold the trust of our community. And that starts with the people who are caring for them when they walk through the doors. So it really is personal, and it really is important that we are taking care of each other first and that our team as a whole is engaged in well and enjoying the work that they're doing.

00;05;43;11 - 00;05;47;29
Brandie Manuel
So we feel like that's really the first piece to then taking great care of our patients.

00;05;48;02 - 00;05;52;22
Elisa Arespacochaga
Absolutely. Especially since most of your patients are your your neighbors.

00;05;52;25 - 00;05;54;28
Brandie Manuel
And in some case, our coworkers.

00;05;55;00 - 00;06;15;27
Elisa Arespacochaga
Absolutely. All right. So let me wrap up with the question about what advice would you give to leaders who are looking to address organizational well-being, who may be thinking, there's too much, there's too much I've got to do to make this, to change our culture, to move our work. What are some of the things that you tried that really helped?

00;06;15;29 - 00;06;49;23
Brandie Manuel
I think starting small and really recognizing that you're probably already doing some of the things already. So things like rounding on your team, rounding with purpose, starting with some of the tools that they teach in team steps, which I am just I've seen the evidence, but I've also seen it work for us. So spending some time getting to know the people if you don't already, getting to know the people that you work with, getting to hear what matters most to them, it may surprise you and spend more time being out and experiencing what it is that they're seeing every day.

00;06;49;25 - 00;06;59;24
Elisa Arespacochaga
Brandi, thank you so much for both the work that you do and the care you're taking of your team. I think it's a wonderful opportunity, and I know you're continuing to spread it to the next generation.

00;06;59;26 - 00;07;01;12
Brandie Manuel
Thank you for having me.

00;07;01;14 - 00;07;09;24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.
 

00;00;00;21 - 00;00;31;26
Tom Haederle
All of the challenges facing larger hospitals and health systems - workforce issues, reimbursement rates that don't meet the cost of care, patient populations impacted by the social determinants of health, and many others, are magnified for rural caregivers. Yet in facing these realities, some rural hospitals and health systems are doing more than coping. They are thriving.

00;00;31;29 - 00;01;05;23
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. After years of smooth functioning, the pandemic hit Augusta Health hard. The Virginia based rural health system started for the first time to experience high rates of burnout and turnover. In this podcast, we hear how Augusta responded to keep delivering the care its patients deserved by including lots of cross-training across multi-discipline care teams, strengthening the role of case managers, and most importantly, transitioned to an accountable care organization.

00;01;05;25 - 00;01;11;09
Tom Haederle
Augusta's example shows how rural independent providers can be successful.

00;01;11;11 - 00;01;39;12
Michelle Hood
Good day. I'm Michelle Hood, I'm the executive vice president and chief operating officer of the American Hospital Association. And joining me today is Mary Mannix, president and CEO of Augusta Health, based in Fisherville, Virginia, and a past board member of the AHA Board of Trustees. We are here to discuss the future of rural hospitals and health systems. But first, let us share our rural credentials, if you will.

00;01;39;15 - 00;02;07;01
Michelle Hood
Certainly, nobody disputes that Maine is a rural state. And as the former president and CEO of Northern Light Health, previously known as Eastern Maine Health Care in Brewer, Maine, I worked with and on behalf of several very rural hospitals, including critical access hospitals, that were members of our system. I also had the privilege of leading the Montana/Wyoming Division of the sisters of Charity of Leavenworth Health System for seven years,

00;02;07;08 - 00;02;22;26
Michelle Hood
certainly, frontier medicine. Likewise, no one disputes that Virginia is a rural state, but your experience in rural health care goes back to your years in Pennsylvania. So, Mary, please share a bit of that experience with us.

00;02;22;29 - 00;02;46;29
Mary Mannix
Well, yeah. Thank you Michelle. So I completed my graduate work in health care administration and have a master's in nursing and an MBA, and then did a two year postgraduate fellowship at the Guthrie Clinic and ended up staying for another 17 years. The Guthrie Clinic is kind of a hub and spoke concept. It serves two states, primarily New York and Pennsylvania.

00;02;47;01 - 00;03;23;06
Mary Mannix
It has its hub located in mid-central northern tier of Pennsylvania, and then a very distributed network of rural clinics throughout the bi-state area. From there, I was then recruited to Virginia, to the Shenandoah Valley, and as you mentioned, in Fishersville, Virginia. And Augusta Health is more of a community focused, less of a hub and spoke, more of a community focused health care organization that does have a far reach throughout many rural communities in Virginia, going north all the way up to Rockingham County, south all the way down to Lexington, and then Bath and Highland.

00;03;23;09 - 00;03;34;05
Mary Mannix
And of course, Augusta County is a very large area as well as the western side of Albemarle. And then Nelson County. So that's a population of about 340,000 people.

00;03;34;08 - 00;03;58;03
Michelle Hood
Well, you can hear from our descriptions of at least some of our experiences in health care that rural is near and dear to us. And our commitment to those providing care to those living in rural America is steadfast. Mary, when I ask health care executives, regardless of where it is that they're currently working, what is it that keeps them awake at night?

00;03;58;05 - 00;04;13;21
Michelle Hood
Hospitals and health systems still call out workforce as a critical challenge. One of the most of the critical challenges. So tell us about your workforce vulnerabilities at Augusta Health and how you are responding.

00;04;13;24 - 00;04;41;22
Mary Mannix
So, you know, we were working on this workforce challenge obviously long before the public health emergency. And then everything just became accelerated with the public health emergency. At Augusta Health we were fortunate we had a very stable workforce. Even when the pandemic started on that fateful day of Friday the 13th, March 20th, and we were able to retain stability in our workforce, we didn't have any reductions in workforce.

00;04;41;23 - 00;05;08;06
Mary Mannix
We did a lot of communication, we did a lot of partnership. And as we were waiting for the surge in our community, we did a lot of cross-training across multidisciplinary teams to prepare, and that served us very well. Our team members were appreciative. They loved how proactively we communicated. If we didn't know the answer to something we said we didn't know, but we'll get back to you and we worked together in a very strong sense of teamwork and spirit.

00;05;08;09 - 00;05;35;02
Mary Mannix
But that third to fourth quarter of I think it was 2021 when Delta morphed into Omicron. We didn't catch a break. And that's when you really started to see some burnout, some exhaustion. And that's what Augusta Health when our turnover really began to spike. And that is when we started to become overly reliant on contract labor to be able to, you know, sustain our mission and serve our community.

00;05;35;04 - 00;06;04;14
Mary Mannix
The areas that have been most challenging have been in nursing, some key areas of physician practice. We have a 260 multi-specialty physician group practice from primary care all the way through various subspecialties. We started to see a little bit of turnover there, even in areas like lab and radiology. Even in mammography, we began to see turnover, a very new phenomenon for us, and one that made us, as I said, very dependent on contract labor.

00;06;04;16 - 00;06;21;23
Michelle Hood
Yeah. So I think, you know, we are still seeing that. And I think the workforce challenges that we have within our field are going to continue. You add on the demographic shifts and the aging of the population and less workforce and more choices for that workforce. And I think we've got challenges for the years ahead.

00;06;21;23 - 00;06;23;03
Mary Mannix
Yeah, definitely.

00;06;23;03 - 00;06;47;19
Michelle Hood
Look forward to working with you further on those. Let me shift gears a little bit and talk about the payment landscape. For many years, we as a field have been working towards a value based care and alternative payment models, not with a whole lot of success, with some success. Certainly there have been pockets of transformation. What does it look like at Augusta Health, and how are you thinking about that?

00;06;47;21 - 00;07;12;12
Mary Mannix
It's a great question. And we knew that this movement away from fee for service into value based models was going to be a really important part of our experience curve in our learning curve. So believe it or not, ten years ago we sat down with our board and said, we think that we really need to conceptualize this as kind of a research and development time for Augusta Health, and that we need to get into the ACO space.

00;07;12;12 - 00;07;38;26
Mary Mannix
I'm going to be honest with you, Michelle. I didn't even fully understand what an ACO was, but I knew that strategically that was the direction we needed to go. We needed to educate ourselves. And so we actually applied way back in 2014 for the Medicare Shared Savings Program. Worked with a consultant to help us complete the application and understand some of the infrastructure that was going to be required, and then began to develop the resources for population health management.

00;07;38;28 - 00;08;01;03
Mary Mannix
We've been through three cycles now with Medicare Shared Savings Program, so we've been in it now for over ten years and have moved from the one-sided upside only model all the way to where we are today. Fast forward, and we are now in the enhanced model where we are doing two-sided risk. We're about to get our fourth year of shared savings.

00;08;01;05 - 00;08;27;00
Mary Mannix
We have learned a lot on this journey. We've learned about how to become competent and understand attribution, complexity coding, chronic disease management and especially as it relates to lived life, social determinants of health. The integral role of not only the primary care physician, but the case manager who's really effective at social complexity. We've developed the analytical tools and the platforms.

00;08;27;00 - 00;08;56;12
Mary Mannix
We've mapped out areas of deprivation and worked with many community partners to begin to address these gaps. So today, we're a smaller ACO. We have probably a little over 8000 Medicare beneficiaries. We have over 300 providers, and we probably have about 100 million of Medicare revenue running through our ACO. But we've learned a lot, and our quality scores range anywhere from between 94 and 98%.

00;08;56;14 - 00;09;30;05
Mary Mannix
Our cost per beneficiary is well below that of the average of all ACOs in the country. And as I said, this has positioned as well. And for the last three years, and soon to be the fourth year, we will have meaningful shared savings that will be able to distribute to those practices that participate in our ACO. What's interesting to me is that I feel like CMS has kind of been leading the pack here, and that our commercial partners have been a little less interested, have been not as eager to move into that experience curve, although their interest is certainly peaking.

00;09;30;08 - 00;09;57;05
Mary Mannix
But we find that commercial insurers really don't necessarily have the sophistication, the reliable and valid data management tools. And in our experience, the strength of commercial insurers ability to lead and partner and service these two-sided risk models, quite frankly, is inferior to CMS. We are working with our commercial insurers, our partners, and we have a couple, you know, very successful alternative payment models with them.

00;09;57;05 - 00;10;16;28
Mary Mannix
But I really feel like we've come the furthest with CMS and now we're in that enhanced program. So our risk is 75% up or down. And again we've been able to move across these now for enrollments with the Medicare shared savings program to more narrow corridors of risk because we've become more competent in population health management.

00;10;17;00 - 00;10;37;11
Michelle Hood
You know, interestingly, when I was with Northern Light Health, we were an early adopter of ACO as well. But I actually had to go to Baltimore to convince CMMI that we could do it in rural Maine, and obviously did convince them that that was possible. And I think, you know, rural communities have some advantage. Rural providers have some advantage.

00;10;37;13 - 00;10;50;10
Michelle Hood
They have lifelong patients that have been with them for the entirety of their life, sometimes multi-generational. They have great community partnerships. They know the social determinants issues really, really well.

00;10;50;10 - 00;11;01;25
Mary Mannix
So I couldn't agree with you more. They know their communities. They feel better than any other model, quite frankly, of health care. And they're nimble and they're agile because of their lack of scale.

00;11;01;25 - 00;11;22;19
Michelle Hood
Yeah, they have to be. Yeah. Yeah, absolutely. Well, we're going to turn to the question of your independence. You are quick to tell us that you are one of the few remaining independent hospitals in Virginia. I know that that can be lonely at times, but you have done a great job with that and continue to strengthen your position.

00;11;22;21 - 00;11;32;29
Michelle Hood
So tell us about how you do that. I know you partner with a lot of organizations and you're a great collaborator, but what do you think it is? It's making you successful as an independent provider?

00;11;33;01 - 00;12;02;01
Mary Mannix
I think it starts with our governance model. We have a board of directors of 16 individuals that live in the community, and so they're very much in touch with the community. And that is an incredibly high accountability model or strong accountability model. We don't make tough decisions and then they go off to different communities to live. They live with the consequences and really think through deeply all of the really important sort of bet-the-farm decisions that health care is faced with.

00;12;02;04 - 00;12;25;03
Mary Mannix
That model of accountability, I think, is where it all begins. There's a tremendous amount of pride in the model that comes from the medical staff, the medical community that comes from our team members, that I also think is really important and critical to keeping everybody engaged in this model of care. We're a sole community hospital, but we only have one hospital, a 255 bed hospital.

00;12;25;03 - 00;12;58;13
Mary Mannix
And the rest of what we do is really on an outpatient basis. I mentioned we've got unemployed physician network of 260 providers. We have 35 regional sites of primary care, subspecialty care, kind of diagnostic and treatment or urgent care. And so we're providing the continuum. The other thing that I think is probably critical to our success, and that comes back to governance, is that our board has made the decision that we're going to take 5% of our investment portfolio and sort of seal it off into an endowment, and it's called the Community Partnership Endowment.

00;12;58;16 - 00;13;29;00
Mary Mannix
And the proceeds of that endowment go toward health equity opportunities that are our identified youth scholarship in our community, but most importantly, to provide grants to not for profit partners that are aligned with us in improving the health of the community by focusing on our community health needs assessment and what those top 3 to 4 issues are. And this has really kind of become a flywheel, if you will, of community collaboration and partnership.

00;13;29;02 - 00;13;56;04
Mary Mannix
And, you know, we have other partnerships as well. You know, we're part of the Mayo Clinic Care Network, which provides great affiliation for resources. Second opinions. We're an affiliate of Duke Oncology Network for Clinical Research for our oncology service line, and we partner with our legislators and our local governments. We have very important partnerships at the state level, you know, with the Department of Health, and we partner with other foundations in the region.

00;13;56;06 - 00;14;14;01
Mary Mannix
So I feel like this model of collaboration, really knowing our community, sort of it all beginning with governance and making a lot of inroads into our community through these partnership models, are probably the most important critical success factors to our ability to hopefully sustain our mission for many generations to come.

00;14;14;04 - 00;14;39;17
Michelle Hood
That doesn't come without a lot of hard work, so congratulations on that. One of the other things that I know you and I share is our desire to be really strong advocates, to increase the role for women in health care leadership. We see many more women CEOs today than we have in the past, and I see a lot of young women coming up in the ranks who are really promising.

00;14;39;19 - 00;14;53;06
Michelle Hood
So interested in how you think the opportunities for women have developed over the years, and how we can continue to open doors for young women, but also other minorities who are underrepresented in our vocation.

00;14;53;08 - 00;15;16;17
Mary Mannix
One of our speakers this morning said, diversity is knowledge, and I just think that that is so true. You know, as women, Michelle, I think we need to remain networked and actively involved in mentorship relationships with our female colleagues at a very intentional level. We need to take risks with our female colleagues and other minorities for succession planning and leadership development.

00;15;16;20 - 00;15;43;12
Mary Mannix
And I really feel like we need to encourage our colleagues, female and other minorities, to sort of take that next step of professional development and responsibility even if you don't feel 100% ready. It's okay to come out of your comfort zone and get into your discomfort zone. I also think we need to talk openly about phenomenon that hold back high performing executives, you know, things like imposter syndrome and, you know, these other cognitive distortions.

00;15;43;12 - 00;16;12;08
Mary Mannix
We need to get those out in the open and tame that emotion by acknowledging its presence and coach and mentor and just reframe around growth and, quite frankly, self-kindness. I think we have to certainly advocate for greater parity in our field across the board, whether that is in fair market value compensation or the types of networking activities that previously have been very gender oriented, whether it be the golf tournament or, you know, what have you.

00;16;12;10 - 00;16;33;23
Mary Mannix
And, you know, I look forward to the day when a health care system CEO is simply a health care system CEO, not necessarily a female CEO, but a health care system CEO. And, you know, it's my hope that we're paving the way for our daughters and that our daughters will continue to pave the paths that we've started. And I think they're going to do that.

00;16;33;23 - 00;16;57;08
Michelle Hood
That's well said, really well said. So I want to thank Mary for sharing her thoughts on the challenges of rural hospitals and health systems, and the challenges that must be overcome to assure a viable and robust rural health care delivery system for the future. I know our listeners appreciate the credibility you bring through a lifetime of experience as a clinician, administrator and leader in rural health care.

00;16;57;11 - 00;17;07;19
Michelle Hood
I am Michelle Hood, executive vice president and chief operating officer of the American Hospital Association. Thank you for listening. This has been an Advancing Health podcast.

00;17;07;21 - 00;17;16;01
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;25 - 00;00;33;17
Tom Haederle
In 2020, Congress acted to prevent any more loss of essential health care services in rural areas due to hospital closures by creating a new designation, Rural Emergency Hospitals. REHs became official on January 1st, 2023, and since then a growing number of rural care providers have voluntarily converted to this category. REHs must provide 24 hour emergency and observation services, and can choose to provide other outpatient services, but cannot have inpatient beds. For rural providers who have chosen this path,

00;00;33;19 - 00;00;49;18
Tom Haederle
it's a significant change, one that has patients asking, what does this mean for me and my community?

00;00;49;20 - 00;01;14;11
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this podcast, we hear from two rural health care leaders who assess how the conversion to rural emergency hospital status is going so far. We learn about the progress REHs are making as a new model for payment and delivery of care, and gain insights on how leaders can build trust and buy in from patients and communities

00;01;14;18 - 00;01;18;23
Tom Haederle
that conversion to this still new category is a good thing.

00;01;18;25 - 00;01;51;15
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico. And Rich Rasmussen, CEO of Oklahoma Hospital Association. We're here to discuss rural emergency hospitals and its progress as a new model of payment and delivery. Welcome, Christina. Welcome, Rich. The Rural Emergency Hospital is a new Medicare provider type created to address the growing concern over rural hospital closures.

00;01;51;17 - 00;02;11;29
John Supplitt
The goal of this new designation is to provide a means to preserve access to essential services for rural residents, and to decrease the likelihood of hospital closures. You each bring a unique and important perspective to the formation of rural emergency hospitals, and I will ask you to share the experience that you have had over the past several months.

00;02;12;01 - 00;02;40;16
John Supplitt
Christina. Guadalupe County Hospital, to get some context. We're located in a remote part of eastern New Mexico on the Pecos Rivers, midway between Albuquerque and the Texas border. This is where multiple federal and state highways converge. It's the only hospital for more than 4500 people living in an area of 3000mi², making you the safety net provider and a resource for emergency services.

00;02;40;18 - 00;02;53;11
John Supplitt
On September 1st of 2023, Guadalupe County Hospital converted from sole Community to Rural Emergency. How has the community responded to the conversion?

00;02;53;13 - 00;03;19;28
Christina Campos
We did a lot of work in advance with our county commission and with our hospital board to ensure that the conversion was almost invisible to the community. The quality of care did not change. The patterns of care did not change. So the community has kind of been quiet about the whole thing. They're just seeing it as trusting that this is a change that we made to be able to ensure the sustainability long term for the hospital.

00;03;20;01 - 00;03;39;08
Christina Campos
The employees were educated, the providers were educated. So we've just had a ton of support, a lot of curiosity. At times there have been some questions: does this change? How do we keep how we keep them? Not necessarily, but it really does change the need for a lot of conversations about patient care on a day-to-day basis.

00;03;39;15 - 00;03;48;20
John Supplitt
So your experience is that it's been largely seamless in terms of the introduction. But you also mentioned there's been a lot of communication that had to be part of the upfront work.

00;03;48;22 - 00;04;16;29
Christina Campos
Yeah, it really does. I think what's really important is to have a trust already within the community. Trust - if you're a government entity, you have to have a lot of trust with your county commissioners or your city council. Your providers have to trust that you know what you're doing, and it's something that you have to have built up well in advance of making this big of a change so that when you're bringing it forward, they already know that you have done the legwork, that you have done the math.

00;04;17;01 - 00;04;26;19
Christina Campos
And this is something that is well planned for, well thought out and not just a reflex to a situation that might be happening at that time.

00;04;26;21 - 00;04;48;23
John Supplitt
Right. I understand, that's very good. Let's talk about planning, but let's talk about the planning that takes place from the bureaucratic perspective. There's a lot of planning that went into your application to convert to a rural emergency hospital. You had to provide an action plan that had a description of the services and staffing. You had to have a transfer agreement with either a level one or level two trauma center.

00;04;48;25 - 00;04;58;12
John Supplitt
And then you had to attest for meeting rural emergency hospital conditions of participation. Share with us how the application process worked for you.

00;04;58;14 - 00;05;26;08
Christina Campos
So the application process really isn't that difficult. But what's really interesting is I had done a lot of education to my colleagues throughout the state of New Mexico Hospital Association, so they knew that we were applying for this REH designation already. And after one of our finance calls for the association, the CEO of the level one trauma center in Albuquerque emailed me and said, hey, Christina, how can we help you?

00;05;26;11 - 00;05;43;14
Christina Campos
So I didn't have to ask them for a transfer agreement. We already had one in place, but it was antique. It was already like in sepia, probably typewritten on a typewriter, but we updated it. And so they were our first. And then we also went with one of the level two trauma centers. Another colleague of mine that reached out and said, we want to help.

00;05;43;14 - 00;06;03;03
Christina Campos
We want to be available to you. What's interesting is even though you have these transfer agreements, it doesn't mean you have to transfer it to them. You just have to have those in place. Then on the action plan, we really did a skinny action plan. We just said, this is what we're offering. This is what we're going to continue to offer.

00;06;03;05 - 00;06;24;25
Christina Campos
Obviously we won't have inpatient beds. And then these are the programs that we will anticipate researching to see if they make sense to add on to our community. So it wasn't really detailed, but we were meeting all the criteria. And I think what really helped me a lot as I was going off of the test was recommendations from ensuring access for vulnerable communities that the AHA developed.

00;06;24;27 - 00;06;42;07
Christina Campos
That I knew that there were certain things that we do want to look at offering in our community, but we are going to offer high quality emergency care diagnostics, including lab and X-ray, and then we're going to expand into these other programs. So it wasn't a really heavy lift for us.

00;06;42;08 - 00;06;50;09
John Supplitt
Okay. Christine is referencing a report that was done by AHA on essential services back, I believe it was in 2016, but it still serves.

00;06;50;11 - 00;06;50;28
Christina Campos
It's relevant.

00;06;50;29 - 00;06;57;21
John Supplitt
Yeah, it's still relevant. What about the challenges that you countered in the conversion towards a rural emergency hospital?

00;06;57;23 - 00;07;15;21
Christina Campos
Ours turned out to be kind of like a backwards conversion. It did not go incredibly smoothly. Part of it is that we were so eager to do it. Reached out to our Secretary of Health and our director of regulation licensing, and they said, hurry up and apply. Go ahead and go through the Pecos system and apply. And we did.

00;07;15;21 - 00;07;39;10
Christina Campos
But the state was not ready, even though they're the ones who urged us to apply. And that was in early December of 2022. And our legislature only meets... they're a volunteer group, so they meet in January for either one month or two months. That year was a two month legislative session. I had to go to Santa Fe on a regular basis and educate the legislators, and have this passed as a statute.

00;07;39;11 - 00;07;56;15
Christina Campos
Now, I argued that critical access hospitals is not written in statute. Why doesn't REH have to be written in statute? But that's what they wanted. So then it was you're going to hear the trend of education and communication. I had to educate the legislators. I had to have the governor on my side to make sure the bill was passed.

00;07;56;18 - 00;08;20;15
Christina Campos
They did not put an emergency clause into it, so it did not go into effect immediately. It did not go into effect until June 16th, two weeks before the end of the fiscal year. But I had already applied to CMS. They had already approved the process. And then when it took so long, my application expired. And then it was a question as did I have to ask for an appeal or reconsideration.

00;08;20;16 - 00;08;40;28
Christina Campos
They didn't know how to handle it. My state didn't know how to handle it, and so it just dragged on until I was able to bring together the Dallas director of CMS with my Secretary of Health and all of the people that were working on this. And then there were many other people through CMS that were working on the project and just trying to understand it.

00;08;41;00 - 00;09;01;00
Christina Campos
We were literally building the plane as we were flying it. That meeting, we were able to get everybody to the table, agree on what needed to be done. Everybody wanted the same thing. They just didn't agree on how to get there. And at that meeting, they came to a conclusion and picked a date, made it September 1st and it was a little bit retroactive.

00;09;01;00 - 00;09;08;20
Christina Campos
We got our license from the state immediately. There's still other conversions stuff that's going on, but I think we'll get into that in a little bit.

00;09;08;20 - 00;09;18;15
John Supplitt
Yeah, a little bit. But I guess when we're listening to your story, what we're hearing is that it takes a champion. You build on the relationships that are there and you have to be persistent.

00;09;18;18 - 00;09;21;13
Christina Campos
Incredibly persistent.

00;09;21;15 - 00;09;49;21
John Supplitt
Well, thanks very much. Rich, let's turn it over to you and get you into this conversation for this model to take effect. As Christina has mentioned, states have to have in place legislation that will allow the licensing, certification and then payment of a new provider type and service. But Oklahoma was among the first states to pass enabling legislation. Share with us why this is a priority for your state and how it came to pass.

00;09;49;23 - 00;10;18;20
Rich Rasmussen
Well, thanks, John. It's a great question. I think the big challenge that we experienced in Oklahoma is that we have a large number of rural hospitals PPS that aren't eligible for conversion to critical access. Now, certainly, Congress has some legislation in front of it that can make that easier, allow that to take place again. And so the membership stepped back and said, what can we do to provide some level of support that will allow these facilities to stay in service in serving their communities?

00;10;18;22 - 00;10;38;03
Rich Rasmussen
When the REH opportunity presented itself, the membership quickly jumped on it. The association passed legislation with the full expectation that we would have conversions, and I believe we had the first one in the nation, I think, in Oklahoma. And, you know, that one was then quickly followed by the second one, and now we've had our third conversion that took place this fall.

00;10;38;05 - 00;10;55;17
Rich Rasmussen
And so for the Perry Hospital, there's no way they could have survived. Along with their sister hospital as well in Blackwell. Had they not had this opportunity, they probably would have been forced into a position to close, or the mothership of the hospital system would have to step back and look at how they could perhaps salvage one of them.

00;10;55;19 - 00;11;18;23
Rich Rasmussen
And this created that lifeline. And I think the moral of the story is, is that to prospective payment hospitals, you would have never thought that. I think most of us, you know, when we looked at, you know, the REH opportunity, we thought it would be critical access hospitals and it really wasn't. And in for the state of Oklahoma, we have several others that are evaluating it just for that very reason, because there's no other way they can survive and continue to support their community.

00;11;18;25 - 00;11;42;25
John Supplitt
Christina was referring to the conversation she had with the New Mexico State Legislature, and how they weren't prepared at the moment. Even though they encouraged you to do it. You had to have had some similar experience in Oklahoma, in the sense that in order to get that legislation passed, you had to have a pretty confident and aware legislature that knew the problems that were confronting some of the rural hospitals in order to respond.

00;11;42;27 - 00;12;06;14
Rich Rasmussen
Oh, absolutely. In Oklahoma, there is a real sense of obligation to ensure that hospitals not only survive, but truly have the opportunity to be successful in serving their communities. And lawmakers also understand that real difficult position that these rural PPS hospitals find themselves in. So it wasn't a heavy lift to get them to agree to do that. They very much wanted to be successful.

00;12;06;19 - 00;12;23;21
Rich Rasmussen
And this is a state that by initiative had passed Medicaid expansion. So you had the public was leaning in on this issue and then you had lawmakers are leaning right in behind it to make sure that the health care system in the state would not only survive, but thrive. And I think that was part of the impetus behind the legislation moving quickly.

00;12;23;23 - 00;12;35;28
John Supplitt
There's a lesson there, too, and in the sense that when the community and in this case, the larger community of the state is behind the initiative, it can happen and happen quickly and effectively.

00;12;36;01 - 00;13;01;11
Rich Rasmussen
Oh, absolutely. And without it, you know, you have communities that, like we see in most of the Midwest, the Mountain West, where folks are traveling hours to get to the next facility. And when you're talking about in Oklahoma, where you have a large agriculture community and a large energy sector as well, accidents do happen. And people have seen that happen to their family members, and they could go to the local hospital.

00;13;01;18 - 00;13;09;04
Rich Rasmussen
The thought of losing that really helped drive the whole narrative around the importance of making sure that we have something in the RH provided that model.

00;13;09;08 - 00;13;34;08
John Supplitt
Excellent, excellent. Let's talk, Christina, about your experience since converting. Payment has been a major focus of providers and policymakers regarding the viability of rural emergency hospitals. You are no longer eligible. In your case, you never received 340B, and swing beds aren't an option under the model you receive, and an additional 5% over the payment rate for hospital outpatient pays.

00;13;34;10 - 00;13;44;04
John Supplitt
And you get an annual facility payment for 2024. That's a monthly payment of about $276,000. Is this sufficient?

00;13;44;06 - 00;14;00;05
Christina Campos
It is sufficient for us. What we did was the math early on. When we were talking about this type of a program with a base payment, kind of similar to a utility model, that you're going to get a base payment for having your ear open. It was intriguing, and I think at the very beginning they were talking more in generalities.

00;14;00;05 - 00;14;19;11
Christina Campos
They weren't being specific about the amount. And then that 5% add on. Well, as a PPS we were getting...as a sole community hospital, we were getting a 7.5% add on. So it's not a bump up. It's a tiny bit of a shaving. And I wasn't really attracted to the program at all until two things happen. Number one, our surveyors came in and said, you don't qualify as a PPS.

00;14;19;11 - 00;14;43;08
Christina Campos
You don't have a high enough census to be a PPS hospital. So we knew we had to do something. Critical access; the math just really didn't work because our sole hospital rate was very generous. It was above cost, so we knew critical access just really wasn't a saving grace for us. When they finally came out with that amount, the 276,000 per month

00;14;43;10 - 00;14;59;20
Christina Campos
and we did the math really quickly to see what we were going to give up. How many admissions are we having? Even if we got reimbursed at our high sole community hospital rate? Is that more or less? That was less. The 3.279 million overall for the year was a lot better for us. So the math has to be very important.

00;14;59;20 - 00;15;19;00
Christina Campos
And I think the other thing that was really important is analyzing the needs of the community. You know, we've talked about what does our community actually need while not being able to have inpatient care. It can sometimes can be difficult on a family because they have to drive. It's not life saving care that you have to have in the community.

00;15;19;01 - 00;15;46;06
Christina Campos
We needed to have emergency services in the community to keep people alive, to be able to get them to other hospitals. And we found also that through the years, through our quality initiatives, our lengths of stay often don't meet that second midnight. People resolve very quickly on modern antibiotics. So we were already struggling to keep them and to get paid for the inpatient stay without them denying it and then having to rebuild as an OBS.

00;15;46;09 - 00;15;49;13
Christina Campos
So it just really suits the way we work.

00;15;49;20 - 00;16;06;12
John Supplitt
Let's talk about quality, safety and the patient focused care. Among the requirements that CMS expects is a quality assessment and performance improvement program. Did you see any challenges in meeting these requirements upon conversion to a rural emergency hospital?

00;16;06;13 - 00;16;31;25
Christina Campos
None at all, because we were already having to meet conditions of participation for PPS, which are stricter than for a critical access hospital. They're a little bit different. We're finding some subtle differences in having to pivot a tiny bit, but if you can meet the conditions of participation and of quality that you had as a PPS or as a CAH, there's absolutely no reason why you're not going to meet the conditions and the quality metrics as an REH.

00;16;31;27 - 00;16;41;25
John Supplitt
Great. Thanks very much. Rich, going back to you. Given the early experiences in your state, do you see rural emergency hospital model expanding in Oklahoma?

00;16;41;28 - 00;17;05;04
Rich Rasmussen
Oh, absolutely. I do think, in fact, we have one hospital that's exploring it right now. With a large number of rural PPS, there really is no option. Certainly there's you know, you've got S 1571, which is before the Senate right now, which one of our senators, Senator Lankford, along with Senator Durbin from Illinois, are sponsoring. That could provide some relief to allow for conversions, again, for critical access that a state could determine.

00;17;05;09 - 00;17;16;10
Rich Rasmussen
But short of that, you know, it's hard to get something passed through Congress. So short of that, this is the only lifeline that we can throw some of these communities. I fully expect that beyond the one that I'm aware of right now, there are others that are exploring the option.

00;17;16;14 - 00;17;20;12
John Supplitt
Well, then what could make this model work for rural hospitals in Oklahoma?

00;17;20;15 - 00;17;45;04
Rich Rasmussen
Well, I think we got part of the apple. I mean, there were some things that most expected would have been part of this package. So allowing REH's to have 340B access to medications. And certainly that part dramatically would help serve communities. Also looking at some type of cost based reimbursement for rural EMS, that's a real challenge that we have as well, that we oftentimes forget about. You know, the swing bed challenge...

00;17;45;04 - 00;18;06;22
Rich Rasmussen
I mean, most of the hospitals that have stepped back and trying to analyze whether they do it or not, was the question of losing that cost based reimbursement for swing beds. And I think if we could fix some of those and maybe we can look at too at some of the issues around distinct park units within these facilities as well, because if we look at behavioral health alone, there's nobody immune from the behavioral health challenges that we have in this country.

00;18;06;22 - 00;18;26;14
Rich Rasmussen
And it's in every stretch of our communities. And so to ensure that we could have a model that not only survives but thrives in these rural communities, I think that's something for Congress to look at. It does not appear that CMS can allow any of these things happen without a statutory change. So I think there's an opportunity for a glitch bill to make the REH even much more effective.

00;18;26;21 - 00;18;36;09
John Supplitt
Let's touch on commercial insurers. We've talked about Medicare and Medicaid, but what's been the response from commercial insurers in terms of this new model of payment and delivery?

00;18;36;15 - 00;19;01;24
Christina Campos
There's such a lack of understanding about REH, and are you a hospital or you're a clinic? We're not a clinic or a hospital. They never heard the definition. They have no idea what it is. So a lot of our contracts with commercials, we kept exactly the same on the outpatient side for ER services or OBS, but we are at least trying to reach out to them to educate them on the new designation.

00;19;01;25 - 00;19;31;18
Christina Campos
There were issues around the taxonomy number that, you know, we kept the same, NPI, so that wasn't the issue. But there is no taxonomy for REH yet that I know of. So we're using an old taxonomy number for rural provider. Where we have seen some challenges is around Medicaid. That it shouldn't be a problem. Some states today have been approved their waiver or their SPA has been approved quite easily to extend their OPPS payments to the REH that they already had in place as a subcommittee provider.

00;19;31;21 - 00;19;42;13
Christina Campos
But right now, we're just trying to iron their out to make sure, because it's not just the payment. The base payment is the Medicaid supplemental payments that if a hospital loses them, would be just very difficult to overcome.

00;19;42;14 - 00;19;43;07
John Supplitt
Yeah. Rich, your thoughts?

00;19;43;07 - 00;20;03;01
Rich Rasmussen
We're fortunate that two of our conversions are tied to larger systems. And so you have the strength of that system and working with payers. But I do think those that are exploring this, that's certainly something to take into consideration. I do know that, you know, we still struggle even with the REHs is like the rest of the nation on the Medicare Advantage plans.

00;20;03;03 - 00;20;23;18
Rich Rasmussen
So that's something we're gonna have to continue to work on. But I did pick up from one of the conversations from one of our administrators, or one of our REHs had indicated that they will receive or they did receive new CCN numbers, and they had to attach those to their REHs. So for those who are considering this, making sure that you do all of this, you know, work at ahead of time, you just kind of like a tabletop.

00;20;23;23 - 00;20;49;00
Rich Rasmussen
What do we need to do? And if you need to bring in some consultants to help you, I know there are a number of them that are out there, but making sure you get it all right because you can't afford to have some of these things disconnected. And I say that because our first REH that did this because they were either first or very close to the first to the with CMS on this, they were approved very early on, I believe it was in April of last year and they didn't get paid till September by CMS.

00;20;49;05 - 00;21;01;15
Rich Rasmussen
My understanding CMS has gotten better on this. So it was just kind of a learning curve for everyone. But for a small community where you're vulnerable financially, making sure you have all of this played out ahead of time, I think is going to be very important.

00;21;01;20 - 00;21;21;12
John Supplitt
Well, there's much to learn. I think we've learned a great deal in the process that's gone by so far. The interest continues to build, whether the consultants agree or not, that interest is continuing to build. And there's been a lot of momentum. And I think as we see some of the tweaks to the legislation, that momentum is going to continue to grow.

00;21;21;14 - 00;21;50;19
John Supplitt
I want to thank my guests, Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico, and Rich Rasmussen, CEO of Oklahoma Hospital Association. Your perspectives on rural emergency hospitals as a new model of payment and delivery are greatly appreciated. And as this model continues to evolve, we'll be looking to you and your colleagues for continued insights into what works and how we can make this model better for patients, hospitals, and the communities we serve.

00;21;50;21 - 00;22;00;11
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;22;00;13 - 00;22;08;23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;28 - 00;00;27;14
Tom Haederle
Ask any hospital leader to name the biggest challenges facing their organization, and their answers are pretty much the same, regardless of size. But for rural care providers, the workforce and financial issues found everywhere are harder to solve, and they're looking to their boards of trustees for help.

00;00;27;17 - 00;00;49;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Join us for this brief but on-point discussion of the role board members can play in helping their hospitals and health systems navigate today's pressing problems, and how the AHA's resources and educational materials can assist board members in turn.

00;00;49;23 - 00;01;12;28
Sue-Ellen Wagner
I'm Sue Ellen Wagner, vice president of trustee engagement and strategy for the American Hospital Association. I'm here at the AHA Rural Conference in Orlando, Florida with Barbara Sowada, who's the president of the board of trustees for Memorial Hospital of Sweetwater County in Rock Springs, Wyoming. Barbara, thank you for joining me today.

00;01;13;00 - 00;01;16;14
Barbara Sowada, Ph.D.
Thank you for inviting me. It's a pleasure to be here.

00;01;16;16 - 00;01;23;02
Sue-Ellen Wagner
Barbara, can you highlight the top three challenges that rural hospital boards are experiencing?

00;01;23;05 - 00;01;58;16
Barbara Sowada, Ph.D.
Obviously, workforce stability, including physician recruitment. That is difficult in rural areas. The financial challenges Medicare and Medicaid do not cover the cost of care right now. And then the commercials are, what should I say,  providing their own challenges with pre-authorization and denials. The other part with the commercials is we're just starting to experience in Wyoming narrow networks through Medicare Advantage.

00;01;58;18 - 00;02;18;00
Sue-Ellen Wagner
Thank you for citing those challenges that we've heard at the conference a lot about the financial and the workforce challenges. So given the challenges that you just talked about, rural hospitals do serve a tremendous value to their communities, and trustees represent these communities. So can you expand a little bit more on that?

00;02;18;02 - 00;02;49;06
Barbara Sowada, Ph.D.
Yeah, the challenges, as you know, the no mission, no margin or no margin, no mission. One of the tricks anymore is to find that balance between what is affordable and what are the community's needs. One of the things that I forgot to mention, but is a challenge nationwide, is behavioral health. And again, in rural areas that I don't know whether it's worse in some areas of the country

00;02;49;06 - 00;02;57;03
Barbara Sowada, Ph.D.
yes, mental health is more challenging than in the urban areas. And again, it's a dearth of resources.

00;02;57;05 - 00;03;15;00
Sue-Ellen Wagner
Absolutely. Yeah. We hear a lot about the behavioral health challenges. My colleague Rebecca Chickey spearheads the behavioral health issues for AHA And we do a lot of collaboration with her. So what can AHA trustee services do to help boards, specifically the rural boards?

00;03;15;02 - 00;03;46;01
Barbara Sowada, Ph.D.
I think the things that you are doing right now, the continuing education...the newsletters...you have a fabulous webinar archival board, the education is fabulous. What was really fun today, is one of the AHA - and I cannot remember her name - employees is working with our hospital to become critical access. So your resources are widespread and greatly appreciated.

00;03;46;07 - 00;04;11;11
Sue-Ellen Wagner
Oh that's good to hear. We aim to help our members. Our website is trustees with an "S" trustees.aha.org. As Barbara mentioned, we do have a wealth of information, including some boardroom briefs, which are 2 or 3 pagers, which also includes some questions that board members can ask about specific issues. We do have a brief on behavioral health, so I encourage folks to listen to that.

00;04;11;14 - 00;04;25;27
Sue-Ellen Wagner
As Barbara mentioned, we do have some great recorded webinars on quality and some other issues. Anything else you want to talk about, Barbara? Maybe something at the rural conference that you learned about or heard about that could be helpful to our listeners?

00;04;25;29 - 00;05;01;19
Barbara Sowada, Ph.D.
One of the things that really delighted me and surprised me are there are several presentations on, I would say, building relationships, having more civil conversations, the need to repair community relationships, sometimes even relationships within an organization. That is part of the focus of this week's conference is truly delightful, and I actually encourage you to do more of that, whether it's written or webinars or what have you, because that communication is just key.

00;05;01;22 - 00;05;11;09
Sue-Ellen Wagner
Well, for folks who weren't able to join us at the conference, hopefully they'll visit our website and utilize some of our podcast and webinars. Thank you for being with us today, Barbara.

00;05;11;11 - 00;05;15;09
Barbara Sowada, Ph.D.
Oh, thank you, Sue Ellen. This is delightful and I love the conference.

00;05;15;12 - 00;05;17;24
Sue-Ellen Wagner
Great. Thank you.

00;05;17;26 - 00;05;26;06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.