Chair File: Leadership Dialogue — Strengthening Rural Health Care with Jennifer Havens

00;00;00;04 - 00;00;39;03
Tom Haederle
Among all of the critical services that rural hospitals provide. Maternal health is among the most important. When a rural provider has been forced to close its doors as far too many have in recent years, mothers and their babies are at risk. Yet, as they have so often, when confronted with serious challenges, hospitals are forming alliances and finding innovative new ways to maintain health care access for community members.

00;00;39;25 - 00;01;07;07
Tom Haederle
Welcome to Advancing Health, a podcast brought to you by the American Hospital Association. I'm Tom Haederle, with AHA Communications. On this leadership Dialog series podcast, John Haupert, president and CEO of Atlanta based Grady Health System and the 2023 chair of the AHA Board, is joined by Jennifer Havens, CEO of UnityPoint Health, the Grinnell Regional Medical Center. That's a 49 bed hospital serving several counties in Iowa.

00;01;07;28 - 00;01;39;01
Tom Haederle
The two Health care leaders discuss how UnityPoint Health has tried to turn lemons into lemonade in Grinnell by applying for and receiving state and federal grant dollars. Jennifer also explains how affiliation with UnityPoint Health gives the hospital access to resources that help improve care delivery and increase health care access for community members. So let's join John and Jennifer as they explore how one rural health organization is finding ways to keep great patient care, including maternal care, alive and well.

00;01;40;09 - 00;02;13;07
John Haupert
Thank you, everyone, for joining me today for another leadership dialog session. I'm John Haupert president and CEO of Grady Health System and board chair of the American Hospital Association. I'm looking forward to our conversation today as we focus on the important topic of rural health care. This discussion is particularly timely for me as I just returned from having the opportunity to speak at AHA's Rural Health Leadership Conference, where leaders from across the country join to share strategies and resources for strengthening the rural health system.

00;02;13;24 - 00;02;44;19
John Haupert
So I am delighted to continue this important conversation with our guests today. We all know that rural health care organizations face unique challenges in caring for patients resulting from geography and staffing shortage, patient mix and patient volumes. As in all communities, rural hospitals serve a critical role in promoting health and well-being. And the pandemic only increased the existing challenges faced by rural health care organizations as they work to meet that mission.

00;02;45;10 - 00;03;25;21
John Haupert
A quick snapshot for you. Almost 140 rural hospitals have closed between 2010 and 2021. In 2020 alone, three dozen hospitals went bankrupt and 19 closed. Research shows that the financial outlook for hundreds of other rural hospitals is considered precarious coming out of the pandemic. But as we consider these sobering statistics, we must also remember that 46 million people, or 14% of all Americans, live in rural communities. With rural hospitals supporting one in every 12 rural jobs in the United States.

00;03;26;02 - 00;03;53;19
John Haupert
As well as for providing $220 billion in economic activity in rural communities. With the pandemic having exacerbated the existing challenges for rural hospitals, it's imperative that we figure out how to strengthen and sustain this vital sector of our hospital network. So again, this is why I'm so pleased to have a hospital leader with me today to talk about the reality of delivering health care in rural America.

00;03;54;09 - 00;04;32;24
John Haupert
I am pleased to introduce Jennifer Havens, chief executive officer of Grinnell Regional Medical Center, based in Grinnell, Iowa. Grinnell is a 49 bed health system serving close to 50,000 residents and several surrounding counties and is a part of UnityPoint Health, which provides care at 21 regional and 19 community network hospitals across Iowa, western Illinois and southern Wisconsin. A registered nurse by background, Jennifer has almost 30 years in health care, spending 20 years at St Jude Children's Research Hospital before joining Unitypoint Health.

00;04;33;25 - 00;05;03;18
John Haupert
Jennifer has been in Grinnell since 2018 and led the Strategic Partnership transition as Grinnell affiliated with UnityPoint Health. She also currently serves as a board member for the Grinnell Chamber of Commerce, as well as the Iowa Health Care Collaborative. So please join me in welcoming Jennifer and let's dive right into our conversation. So, Jennifer, as I mentioned, there are a multitude of challenges threatening the stability of rural hospitals.

00;05;04;13 - 00;05;09;03
John Haupert
Tell us about any distinct challenges that you face in a rural community.

00;05;09;19 - 00;05;34;29
Jennifer Havens
Well, thank you, John. It's really an honor and a pleasure to have this opportunity to chat with you today. And certainly I think it's it's very appropriate on the heels of what you discussed around rural hospitals closing. One of the specific service lines that I would like to highlight today is maternal health. Because if hospitals aren't closing, hospitals are choosing to close maternal health units.

00;05;35;22 - 00;06;20;15
Jennifer Havens
In fact, since 2010, over 100 rural hospitals have chosen to close obstetrics, and 20% remain at high risk for closing. And there's a multitude of factors for this from recruitment of the specialized providers to the staffing challenges of 24/7 and the low delivery numbers, all of those things combined. And the financial challenges, I should mention as well, have made it very difficult for many rural hospitals to continue what I consider to be a very critical service in rural America. Specifically in Iowa, out of 119 hospitals, there's only 56 hospitals that continue to deliver babies.

00;06;20;27 - 00;06;47;01
Jennifer Havens
We happen to be one of those, and we sit in a four county area where we are the only hospital that continues to deliver. So a lot of concern around what's next in terms of making sure, number one, we stabilize the 56 hospitals that we continue to have delivering babies, as well as making sure that we're providing an environment that is safe and high quality.

00;06;47;19 - 00;07;14;23
John Haupert
Well, thank you for sharing that, because that is such a critical issue. And I know that that is an issue facing rural hospitals, not only in Iowa, but across the country. And we're beginning to see that even arise in urban areas as well, with hospitals reevaluating provision of O.B. and obstetrics services within their community. As you know, we as a field collectively have had serious workforce issues coming out of the pandemic.

00;07;15;10 - 00;07;20;08
John Haupert
Can you tell us about how workforce challenges are playing out for you and in your rural communities?

00;07;20;19 - 00;07;46;11
Jennifer Havens
Yes, I don't think our workforce challenges are any different than any other hospital in terms of those positions that are incredibly hard to recruit right now and where we're using travelers. And the thing I will call out for rural health care is emergency medical services or access to ambulances, not only for the hospital but for the residents and the communities that we serve.

00;07;47;04 - 00;08;17;08
Jennifer Havens
In Poweshiek County we have 20,000 residents. Poweshiek county is 600 square miles and we have three ambulance services in total that are staffed partly by employed EMTs or paramedics, and the rest are volunteer. And close to all EMS providers, half of all EMS providers in Iowa are volunteer, and that is becoming harder and harder to staff in Iowa.

00;08;17;08 - 00;08;46;02
Jennifer Havens
The response times nearly double what the national benchmarks are. And so I don't think that people realize when you call 911, it might not necessarily mean that you get an instant response. And so I feel that we have a strong obligation to help stand up these services again, to stabilize them and make sure that our patients have the right care that they need prior to arriving in our emergency department.

00;08;46;23 - 00;09;14;18
John Haupert
Another excellent point, because pre-hospital medicine, as we all know, is such a critical part of getting people timely care at a hospital. And those were some startling figures you just shared with us. So advocating for financial sustainability of hospitals is a key priority for AHA as well, and that certainly includes our rural hospitals. Can you share with us how mounting post-pandemic financial pressures have meant for you and your organization?

00;09;15;05 - 00;09;41;05
Jennifer Havens
Yes, John, I think, again, this is not an area where our pressures are unique and we are all likely looking to the same levers to pull to make sure that we can turn our situations around, reducing overhead, freezing and reducing indirect overhead positions, decreasing our access to capital, all those things that we need to be doing to be financially responsible.

00;09;41;13 - 00;10;06;02
Jennifer Havens
I think one of the things I like to highlight is how we have tried to turn the lemons into lemonade in Grinnell, and that is through the application for grants. There are so many grants available, yet they can often feel very daunting and overwhelming, especially in a rural hospital where you have a limited number of people who already wear so many different hats.

00;10;06;02 - 00;10;38;04
Jennifer Havens
And so how do you take a grant on and put a solid application in to help with some of these mounting pressures? So I am really proud to say that we have worked hard to make lemonade this year and we have been awarded $2 million in state and federal grants as a result of that work. And we've just we've just switched gears and we've reallocated prioritization in our organization from maybe what they used to do to now we need you to focus on this to help us through this difficult time.

00;10;39;01 - 00;10;45;13
John Haupert
Wow, that is fantastic. $2 million. That's that's sizable work. Congratulations. That's great.

00;10;45;16 - 00;10;46;18
Jennifer Havens
We're very happy.

00;10;47;10 - 00;10;54;01
John Haupert
From an AHA perspective, are there policy changes that you would like to see that could help rural hospitals like yours?

00;10;54;19 - 00;11;24;03
Jennifer Havens
Yes. So as a rural hospital, we are known as a tweener because we are not a critical access hospital. We don't qualify for DISH. We're not 340 B And so we fall between the cracks, if you will. And it's a tough place to be from a reimbursement perspective. So fortunately, in 2004, CMS recognized this category of hospitals with less than 51 beds in need of some extra help and support.

00;11;24;03 - 00;12;02;24
Jennifer Havens
And they created a program called the Rural Community Demonstration Program to test the feasibility of providing cost-based reimbursement for inpatient services. Since 2004, despite the fact that it was a demonstration, they have renewed this program every five years up until last year, where we breathe another sigh of relief that this program is going to continue. There are currently 26 hospitals in the United States that are part of this demonstration and this demonstration is worth $1,000,000 to our bottom line.

00;12;02;24 - 00;12;34;23
Jennifer Havens
And I think it is very safe to say we would be in an even much more difficult spot without access to the program. So I think all of us in this program are acknowledging the fact that we've proven feasibility, that it's necessary for something like this to continue. So we would love to see this permanent legislation. Or the other thing that would be even better is that they would open the critical access hospital designation up to the 26 of us that participate.

00;12;35;12 - 00;12;58;07
John Haupert
That's fantastic. Actually, over the last couple of days when I was at the rural health conference, actually heard from several institutions just like yours that fall in between those definitions and they express that same concern. So definitely a policy issue that we need to look at. In my introduction I mentioned that Grinnell affiliated with UnityPoint Health five years ago.

00;12;58;19 - 00;13;04;28
John Haupert
Can you share with us what it means to be part of a larger system and possibly any benefits of having that affiliation?

00;13;05;15 - 00;13;44;04
Jennifer Havens
Yes, This organization was nearing bankruptcy in 2016 and 17, and they made the decision to affiliate at just the right time and I truly believe had a pandemic hit two or three years earlier, our organization wouldn't be here today to provide the needs for our communities. So the affiliation gave us access to all kinds of resources and not just financial stabilization, but to financial and human resources platforms that didn't exist to epic, an electronic medical record, to procedures and policies.

00;13;44;04 - 00;14;11;29
Jennifer Havens
But I think even more importantly, it gave an independent community hospital that was trying to do everything on its own access to subject matter experts. So we have departments in rural hospitals of one or two people that are trying to create their own policy and procedures and research best practice. And there was instantly access to this world of people that understood the language they were speaking that had policies in place already.

00;14;11;29 - 00;14;22;05
Jennifer Havens
And so there's tremendous benefit outside of just those that we experienced during pandemic that we experienced before and continue to experience now.

00;14;22;27 - 00;14;30;09
John Haupert
Thank you for that. Has been part of UnityPoint impacted your ability to maintain or expand access to services?

00;14;30;28 - 00;15;02;06
Jennifer Havens
It absolutely has. And I think one of the examples I would share is this hospital went without any orthopedic surgery, visiting specialists or any providers here for ten years. So everyone was having to travel an hour, either east or west, to get to an orthopedic surgery council of any kind. When we joined Unitypoint Health, they had a very strong affiliation and relationship with a big orthopedic practice in Des Moines.

00;15;02;06 - 00;15;33;20
Jennifer Havens
And as a result of that solid relationship they had with them, we were able to easily get our foot in the door and have conversation around how we can be more collaborative. How can we start bringing a couple of your docs here to provide a visiting specialty clinic which is now converted into. We have a full time orthopedic surgeon here, 24/7, seven days a week that is lives in our community and is a part of that orthopedic practice.

00;15;33;21 - 00;15;41;06
Jennifer Havens
So it is truly, I think, a Cinderella story around what joining a larger system can help you do.

00;15;42;00 - 00;16;07;12
John Haupert
Well, absolutely. And a great testimony to partnering with another system to be able to improve access to those important services. We know that in some rural areas there's a lack of local public health resources leaving the hospital to expand its role beyond an anchor health care organization. How have you worked as a trusted community partner to convene other stakeholders to improve health and wellness in your community?

00;16;07;29 - 00;16;39;16
Jennifer Havens
Yes. So we are fortunate in Grinnell to have the public health department as a department of the hospital. And so we already have an organically great relationship with public health and we work hand-in-hand, certainly through the pandemic. It made some of those things much easier. But also as we continue to think about our role, not just within our four walls of improving the health of the people and the communities we serve, which is our mission.

00;16;39;26 - 00;17;13;20
Jennifer Havens
But how do we do that outside of our walls? And I think the pandemic brought us all in for two years. We had to survive through those years and through many challenges that that that forced internal focus. However, fast forward, we just were able to complete our community health needs assessment and we had some great data back around how we can continue to be that convener of improving health and the communities we serve.

00;17;14;01 - 00;17;49;22
Jennifer Havens
I think the other challenge as a community rural hospital is that people often look to you to be the owner of all the needs within the community and it's important to recognize that we certainly play a role in all the unmet health care needs in the communities we serve. But many times it's just helping to be that convener and taking charge and organizing the effort because there are many resources and nonprofit organizations that have similar missions and similar desires to meet these needs.

00;17;49;22 - 00;17;54;20
Jennifer Havens
So that convening word, I think, is critically important as we move forward.

00;17;55;24 - 00;18;22;06
John Haupert
I couldn't agree with you more, and you're so right that we so often get looked to to own all of the issues and we simply can't do it all. But we sure can partner with other people and other institutions and convene those individuals to come to the table to help solve the problem. So in that vein, what strategic partnerships or initiatives have you been able to create or join within your community to address unmet needs?

00;18;22;23 - 00;19;01;23
Jennifer Havens
Yes. So we have a community health partnership network and it is made up of all the nonprofits that serve the county where we reside. They meet at least monthly to discuss their own initiatives, but also to discuss specifically what is that one thing that we can work on, collectively together to move forward within our county? And most honest, that is that's a conversation that's just really getting restarted post-pandemic, where people actually feel like we can think about bigger things, we can think about our impact in bigger ways.

00;19;01;23 - 00;19;16;01
Jennifer Havens
And so I anticipate in 2023 that we're going to have a couple big rocks that are going to come out of this solid community group that will help us again to refocus outside of our four walls.

00;19;17;00 - 00;19;43;14
John Haupert
Great. Thank you for that. That's important work. So let's end our questioning on a positive note. While there is no debating that the pandemic has been hard and has underscored the growing sustainability threats for rural hospitals, we've also seen the amazing compassion of our caregivers and the strength of our field to care. What are you most proud of in terms of how your hospital battled the pandemic and cared for your community?

00;19;44;08 - 00;20;18;02
Jennifer Havens
Yes, I think we all have those stories that we can pull up and think about, and I'm grateful that they can be memories now as we reflect on what we've been through. I think many of us during that time were or we didn't just become the hospital on the corner anymore, but we represented our value to the community through access to emergency care, hospital beds, outpatient COVID treatments, and certainly the vaccines in the beginning.

00;20;18;13 - 00;20;43;11
Jennifer Havens
I think the thing that I am most proud of is how we stood up to care for our aging community, outside again of our four walls. So interestingly enough, Grinnell has the highest percentage of people who have Social Security per capita of any community in Iowa. So we have two very large continuing care retirement communities in town.

00;20;43;21 - 00;21;11;09
Jennifer Havens
And we quickly realized in the onset of COVID that these the nursing home component particularly were struggling and they were sending any of their residents with any kind of symptoms straight to our ED. And so we were getting incredibly full and overwhelmed with patients that didn't really need to have an emergency level of care. So we formed an internal team.

00;21;11;09 - 00;21;43;11
Jennifer Havens
We had a physician champion and a few nurses who are incredibly passionate about packing their bags, supplies and medicines and going to these nursing facilities on a daily basis. So they did the testing, they did education, they provided fluids and in the outpatient drugs that were necessary and other treatments that allowed the residents to stay in their home and certainly kept them out of our hospital where we were needing those beds freed up for other more critical patients.

00;21;43;14 - 00;21;51;13
Jennifer Havens
So this was a huge win-win, and I believe a great example of how we helped battle the pandemic and come together as a community.

00;21;52;09 - 00;22;01;14
John Haupert
Yeah, that is a great example indeed, to be able to take the care where it needed to be provided and not having to do that within the walls of the hospital.

00;22;01;20 - 00;22;02;02
Jennifer Havens
Yes.

00;22;02;29 - 00;22;09;26
John Haupert
So did you look forward? Are there any key strategies or innovations that you feel must become a priority for rural hospitals?

00;22;10;18 - 00;22;34;24
Jennifer Havens
Yes. So, you know, rural hospitals, we we tend to believe we need to be all things to all people. And I think as our resources become more and more strained, our ability to recruit and retain the providers that we need to be all things to all people, we've got to start to think about how can we do this differently?

00;22;35;05 - 00;23;04;27
Jennifer Havens
You know, I do believe telehealth is one of those options, but it's been very slow to adopt in in rural America and specifically in Iowa. And I believe we're not going to be able to use telehealth as that only solution to provide access. And even for services in crisis such as maternal health - you know, how do we think about I might not be popular by saying this, but working across the barriers of being a competing organization.

00;23;05;04 - 00;23;39;13
Jennifer Havens
And if you provide maternal health in four counties, how do we begin to think about what do the moms in our in our state need and how do we create those maternal health hubs that are equidistant where we work across competing lines instead of worrying about just our volumes and how we do as a specific organization. How do we work collectively as an entire state working to solve the maternal health crisis and break down those barriers that present themselves?

00;23;39;29 - 00;24;00;18
John Haupert
Whether that's music to my ears, I often times think of how we can better create networks of care even among competitors. As long as we're serving the needs of the patient and doing a better job of that. It'd be great if we could put those competitive powers to rest as well as we do a better job. So thank you for that.

00;24;01;14 - 00;24;09;14
John Haupert
Well, I know we could keep talking, but I want to be mindful of our listeners' schedules, so we'll stop here. Jennifer, thank you again for joining me today.

00;24;09;15 - 00;24;10;22
Jennifer Havens
Thank you, John.

00;24;10;22 - 00;24;33;16
John Haupert
I greatly appreciate you sharing your thoughts and insights on rural health and the unique health challenges that exist in the rural communities. It is important for all of us to remain mindful of how the challenges we all are facing as a hospital field can sometimes have an even greater impact on a small, rural organization. So until next time, thank you to everyone for joining us today.

00;24;33;28 - 00;24;51;12
John Haupert
I hope you'll be back for next month's leadership dialog. Thank you.