National Rural Health Day 2023

00:00:00:28 - 00:00:40:18
Tom Haederle
According to the Centers for Disease Control and Prevention, people of American Indian and Alaska Native descent, also known as indigenous, are twice as likely to experience pregnancy related deaths as white women. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. November is National Native American Heritage Month, and November 16th is National Rural Health Day.

00:00:40:20 - 00:01:09:08
Tom Haederle
Making this a fitting time for this podcast discussion of the experiences of American Indian and Alaska Native Communities indigenous to the United States. In this podcast, Julia Resnick, AHA's director of Strategic Initiatives, is speaking with Dr. Dr. Tina Pattara-Lau a maternal and child health consultant with the Indian Health Service Office of Clinical and Preventive Services, and Dr. Johnna Nynas, an obstetrics and gynecology specialist from Sanford, Bemidji Medical Center.

00:01:09:10 - 00:01:26:02
Tom Haederle
The group explores some of the common challenges, disparities and systemic barriers indigenous people experience in pregnancy and postpartum, and discusses ways hospitals and health care organizations are combating these challenges to provide adequate and culturally competent care.

00:01:26:04 - 00:01:45:25
Julia Resnick
Welcome, Dr. Pattara-Lau and Dr. Dr. Nynas. We're so happy to have both of you here today to talk about maternal health for American Indian and Alaska Native communities. So let's start with Dr. Pattara-Lau. Can you share with our listeners some background and recent statistics on the state of maternal health for indigenous communities in America?

00:01:45:27 - 00:02:07:23
Dr. Tina Pattara-Lau
Thank you and thanks for the opportunity to elevate this important topic today. We know that maternal morbidity, mortality for American Indian and Alaska Native birthing persons is usually 2 to 3 times that of the white non-Hispanic population. And we see these disparities when we provide care in the community. But several new studies have recently highlighted some inequities among indigenous birthing persons nationwide.

00:02:07:25 - 00:02:31:18
Dr. Tina Pattara-Lau
I'll note that while some studies do use gender specific pronouns, IHS is inclusive of all birthing persons. So last year, a CDC report from the State Maternal Mortality Review Committee found that 93% of American Indian and Alaska Native pregnancy related deaths were preventable. 64% occur postpartum. The leading causes of death included mental health conditions such as death by suicide or overdose, as well as hemorrhage.

00:02:31:20 - 00:02:58:18
Dr. Tina Pattara-Lau
And earlier this year, two studies published in JAMA found that while maternal deaths in U.S. hospitals have declined. So there more maternal morbidity has actually increased. And specifically, American Indian and Alaska native mortality decreased over the study period, but pregnant patients still experienced a higher risk of maternal death compared with white patients. In a second study found that severe maternal mortality in more states was higher among American, Indian and Black populations.

00:02:58:20 - 00:03:18:07
Dr. Tina Pattara-Lau
And so while the data doesn't provide us with the full story, we need to acknowledge that there are systemic gaps and barriers to maternity care that contribute to the inequities for indigenous birthing persons. And so IHS, along with other health care systems, have turned to innovative approaches and increasing care in the community and support before, during and after pregnancy.

00:03:18:09 - 00:03:29:20
Julia Resnick
That is absolutely heartbreaking and thinking about those communities, what are some of the common challenges or barriers to getting proper pregnancy care and postpartum care?

00:03:29:22 - 00:03:56:13
Dr. Tina Pattara-Lau
Certainly the effects of historical trauma, including systemic racism, can actually last generations. And so together with adverse childhood experiences or aces and social determinants of health such as transportation, housing or access to electricity or clean running water, they disproportionately affect American Indian and Alaska native birthing persons. And so this can contribute to a higher rate of co-morbidities during pregnancy, including the mental health conditions and substance use.

00:03:56:15 - 00:04:21:06
Dr. Tina Pattara-Lau
I must acknowledge that this history does contribute to mistrust as well as avoidance seeking care within institutionalized health care systems. And as a non-native provider, I have learned it's important to be open and curious and practice humility. Acknowledge the trauma and the bias across generations, along with resiliency of cultural practices to help build trust and provide culturally safe care. Specifically in the rural setting

00:04:21:09 - 00:04:44:06
Dr. Tina Pattara-Lau
significant barriers the closure of rural obstetric hospitals. March of Dimes reports that one third of U.S. counties are considered maternity care deserts. 300 birthing units are closed since 2018, about 70 in the last year. Many American Indian and Alaska Native families live in rural communities. So 13% delivery, maternity care, deserts and about a quarter of babies are born in areas of limited or no access to maternity care.

00:04:44:09 - 00:05:06:09
Dr. Tina Pattara-Lau
So while IHS provides care to the 574 federally recognized tribes, births occur in all 50 states and the District of Columbia, and 25% of those American Indian Alaska Native births occur at an IHS or tribal facility, which means that 75% occur outside our system. So we've worked to maintain rural access by working in close collaboration with family practice physicians, midwives.

00:05:06:11 - 00:05:43:21
Dr. Tina Pattara-Lau
We realize that birth is commonly attended by relatives, including elders and aunties. So indigenous birth workers also have an important role to play in providing care. And then in urban areas, about 70% of Americans or Alaska Natives reside in those communities, often living apart from family and traditional cultural environments. And that presents a mental and physical challenge. So urban clinics will try to meet the needs of the community by incorporating culturally specific activities or provide things like mandatory health care, community-based outreach programs like health fairs, and then afterschool programs for youth who are focused on nutrition and fitness or native arts and crafts dance.

00:05:43:24 - 00:05:50:29
Julia Resnick
That's wonderful to hear. So turning to you, Dr. Nynas, can you talk to us about your hospital and the communities you serve?

00:05:51:01 - 00:06:21:06
Dr. Johnna Nynas
Sure. So I work for Sanford Health in Bemidji, Minnesota, which is located in the far northern part of the state. And we have three surrounding American Indian reservations that patients do receive care from our facility in coordination with their local facilities at their IHS site. And within our region, we're basically located in one of the most socially kind of deprived and poorest regions of the state and also very geographically isolated.

00:06:21:07 - 00:06:50:12
Dr. Johnna Nynas
So in keeping with the national trends that we're seeing, we face the same kind of barriers. We're seeing a lot of adverse impact related to those social determinants of health, high rates of poverty, substance use, domestic violence, trauma in the home. Subsequent issues related to generational trauma. The geographic isolation is particularly problematic. Thinking of northern Minnesota, we're heading into winter and in addition to just distance being a barrier, a weather is a huge barrier for us.

00:06:50:13 - 00:07:12:23
Dr. Johnna Nynas
So when you have a patient that travels 60 miles to get to an appointment and has transportation difficulties and then we throw a snowstorm in the middle, that's a completely unseen barrier that other places of the country don't have to consider. And then again, within the community, we're working really hard to acknowledge that there is still systemic racism within the community and implicit bias.

00:07:12:26 - 00:07:40:02
Dr. Johnna Nynas
And we're really trying to be mindful of our role within that. And again, be curious and ask those questions and really make some efforts to train our staff and our our nurses and collaborate not just within the health care systems themselves, but also with community organizations that are supporting indigenous birthing persons and improving our own cultural competence, if you will, within the community and try to rebuild that trust.

00:07:40:05 - 00:08:00:12
Julia Resnick
Yeah. So I want to dig into some of those opportunities because you both really outlined what the challenges are. But as we're seeing is we're talking to health care organizations. I'd love to hear more about what you think hospitals and health care organizations can do to address those challenges and disparities when they're treating American Indian and Alaska Native individuals.

00:08:00:14 - 00:08:03:01
Julia Resnick
Dr. Pattara-Lau I will start with you.

00:08:03:03 - 00:08:27:13
Dr. Tina Pattara-Lau
Well, we know pregnancy is a stress test for the body, you know, physically, mentally and spiritually. And underlying comorbidities, mental health conditions may become more acute. Some examples of where the additional stressors can affect American-Indian, Alaska Native populations are that in some states, substance use during pregnancy can result in involvement of the legal system, including incarceration or child protective services.

00:08:27:16 - 00:08:58:15
Dr. Tina Pattara-Lau
There is a mistrust of the health care and legal systems, and that's a barrier to establishing prenatal care, but also to timely interventions such as treatment to prevent congenital syphilis. So some families are fearful there will be hurt by their health care provider due to this underlying systemic racism. The CDC also recently released a report: one in five women reporting mistreatment while receiving maternity care, one in three of black, Hispanic, multiracial women watching this treatment and 45% women held back from asking questions or sharing concerns.

00:08:58:17 - 00:09:19:01
Dr. Tina Pattara-Lau
So what can we do? Well, while we hope all pregnant, postpartum patients are treated with respect, we know this is not always the case. And so starting with the patients, I share with my patients as well, please continue to advocate for yourselves and your relatives. You know your body best. When something feels wrong, tell someone, get help. Bring a trusted family member or friend.

00:09:19:04 - 00:09:42:25
Dr. Tina Pattara-Lau
Many patients, as Dr. Nynas mentioned, have access to tribal MCH programs and organizations such as the Alaska Native Birth Workers Community or the Navajo Breastfeeding Coalition to provide that support. And then looking at ourselves within our care systems, what am I doing to promote cultural safety? Am I elevating Indigenous leaders, elders, members of the community to create systems by the people for the people they serve?

00:09:42:27 - 00:10:10:09
Dr. Tina Pattara-Lau
Am I talking about things like first foods and medicines, indigenous birth and traditional healing practices. And so you may be familiar with the CDC's HRSA campaign that was launched in January for American Indian Alaska Native people provide resources and education, specifically from tribal communities as well as urgent maternal warning signs. But also as a society, as we begin to share more of our stories around mental health and reducing the stigma around mental health and seeking support. HRSA

00:10:10:09 - 00:10:39:25
Dr. Tina Pattara-Lau
recently launched last year, the Maternal Mental Health Hotline for 20/7 confidential support before, during and after pregnancy. It's available to patients and families with call or text translation services in 60 languages, including Navajo. Their number is 1-833-TLC-MAMA. So again, just some examples of the community and the national level support that we can find for our patients in the field.

00:10:39:27 - 00:10:56:06
Julia Resnick
And that national maternal mental health hotline started by HRSA, really crucially important. So, Dr. Nynas can you talk more about what you're doing at your hospital to increase access and availability of resources to improve maternal health outcomes for Indigenous women in your community?

00:10:56:09 - 00:11:45:05
Dr. Johnna Nynas
Sure. We've been really fortunate. Back in 2021, a group of health care providers within northern Minnesota, which included Sanford Health, as well as our IHS partners at Red Lake Nation and Leech Lake Nation and several community organizations came together and developed a program that we're calling Families First. And we were the 2021 recipient of a rural maternity and obstetric management services grant from HRSA to support development of this collaborative to really look at how we can target those issues that contribute most to adverse maternal outcomes, particularly among American Indian women within our region, and also how to create a foundation and to keep this sustainable for years to come.

00:11:45:08 - 00:12:07:23
Dr. Johnna Nynas
And so what came out of this is we've partnered together with several organizations to make sure that we are providing high quality and culturally related health care for moms and their families. We're trying to build trust and basically ensure that the care that these patients deserve is available. And our goal is for the next seven generations. So within that, there's several different moving programing pieces.

00:12:07:25 - 00:12:32:02
Dr. Johnna Nynas
The most critical one has been establishing high risk OB care coordinators at all of the sites that are providing obstetric care services. So we created the position and provided the initial funding for these positions and really what they're responsible for is their nurses who know all of the high risk patients within provider services and really kind of does the double checking to make sure nobody falls through the cracks.

00:12:32:04 - 00:12:50:01
Dr. Johnna Nynas
So if a patient hasn't been sending in their blood sugars or has missed an appointment with a consultant or missed an ultrasound, they're reaching out to the patient to find out what was that barrier that was difficult for you to come in for that appointment or to finish that part of your care and get them reconnected with care.

00:12:50:08 - 00:13:18:26
Dr. Johnna Nynas
And as we are seeing just a nationwide shortage of real health care providers and in particular a significant shortage of rural obstetric care providers, we need to support our practices in any way we can, and this has been a helpful way to do that. One of the extensions of this is increasing our home visiting nursing program capacity. One of the extensions of that was a partnership with Bemidji County Public Health to increase home visiting nursing programs.

00:13:18:26 - 00:13:40:18
Dr. Johnna Nynas
And so they established a goal of trying to complete 40 in-home visits for 2023. And as of June of this year, they had completed 143 home visits going way beyond their goal. And that is the direct result of the work that our high risk OB care coordinators are doing. For transportation barriers, obviously, that's a huge issue in our region.

00:13:40:20 - 00:14:07:03
Dr. Johnna Nynas
We have purchased a van that is going to be providing transportation for patients to appointments and ultrasounds. We are taking some lessons we've learned from Sanford Bemidji Behavioral Health Program, which did a similar program where they would provide transportation. What they found was when you provide the transportation for the patients, you can operationalize the cost of the van and the driver by decreasing your no-show rates.

00:14:07:06 - 00:14:32:21
Dr. Johnna Nynas
So that's something that we're going to implement for prenatal care and hopefully use that as a model for other health care agencies and also within our health care system as well. We are developing a specific, culturally competent group prenatal care program within our IHS site. So that prenatal care is a different model of providing traditional prenatal care. Patients still have their individual assessments.

00:14:32:21 - 00:15:13:23
Dr. Johnna Nynas
They still receive the American College of OB-GYN recommended evaluations and testing at the appropriate intervals, but they also get an additional 2 hours of education on any topic related to pregnancy and postpartum. So we're using that as an opportunity to weave together kind of traditional beliefs of birthing and child care and postpartum and those customs that exist within our tribes, along with the teachings that are out there and accepted by the national organizations as best practice. And weaving them together in a way. And also helping to really foster some support within the community itself,

00:15:13:25 - 00:15:35:24
Dr. Johnna Nynas
so women are also working together and supporting each other to keep those relationships going. And it's really about not only educating the individual person, but also making sure that they have the tools. So if they have a friend down the road or someone they know reporting symptoms, hey, that sounds like preeclampsia. You should really call your doctor. Maybe we should get you to the E.R. that's familiar to me.

00:15:35:26 - 00:16:17:01
Dr. Johnna Nynas
And that's where we can really make an impact, is improving health literacy and knowledge within our communities and then improving our access to virtual care. Broadband access can be really limited in rural areas, can be cost prohibitive for many people. And we are looking at putting infrastructure into some of the satellite clinics within our region to improve access for virtual visits, to decrease some of those transportation needs and really bring obstetric care to where women live rather than expecting all patients to come to us. And then internally we're doing a lot of work surrounding trauma stewardship and trauma informed care, a lot of education for our staff and our nurses education regarding low intervention, birth

00:16:17:01 - 00:16:49:06
Dr. Johnna Nynas
processes and how to support a low intervention birth. And we're really starting to see some improvement in some of our outcomes since doing those. And we've seen from 2017 to 2023, we've seen a 77% decline in CPS holds for babies for cases of neonatal abstinence syndrome in maternal substance abuse. We've also implemented within our hospital a different way of monitoring for neonatal abstinence when women have been using substances in pregnancy called eat sleep console.

00:16:49:08 - 00:17:15:06
Dr. Johnna Nynas
And what we're seeing coming out of that is we're seeing decreased neonatal length of stay, fewer admissions to our special care nursery for morphine administration. And we're seeing a higher number of referrals of women to drug and alcohol treatment programs and increased use and referrals to medication assisted therapy programs. So many good outcomes coming out of multifaceted work that we're doing as a collaborative team within our community.

00:17:15:09 - 00:17:30:10
Julia Resnick
That's wonderful and I love hearing about how you're weaving together traditional practices alongside medical ones to really meet the needs of the pregnant people in your community. I wonder if you have any stories that you can share that can really bring this program to life for our listeners.

00:17:30:12 - 00:17:54:18
Dr. Johnna Nynas
We're still in the phases where we're building the programing, but this is the idea. Where it came from is if I can have a patients who might be seeing a provider up in Red Lake with her local provider receiving group prenatal care up there, forming relationships with other women in her community and then transition to our hospital, which is the regional kind of birthing hub for our region.

00:17:54:20 - 00:18:17:25
Dr. Johnna Nynas
She's coming in basically having appropriate screenings. Any chronic medical conditions have been addressed and are controlled going into her pregnancy and delivery? We are doing a lot of work around what are some of those spiritual practices and cultural practices that are really important to me? Who are the people who are going to support me during my birth process and what should that look like?

00:18:17:28 - 00:18:44:22
Dr. Johnna Nynas
And sending that with the medical record, as we would lab results or other test results, because it's an important part of the care piece. And when those patients come to us for that transition of care and delivery, making sure that we're incorporating those practices at the bedside and providing those necessary resources. And the goal is that when all of our patients end up delivering, we're going to see better outcomes for moms, better outcomes for babies.

00:18:44:22 - 00:19:31:15
Dr. Johnna Nynas
We're working to get good coordination so those women can be seen by their initial OB provider at their IHS clinic locally within two weeks of delivery for that supportive postpartum care. We're also working with other community groups who do similar work. Some Indigenous doulas, lactation consultants within the region to really support that in-home care that happens postpartum. And we can identify those women who are at risk for postpartum depression, substance abuse, relapse, who may have different needs just within their own household, be it access to water, to heating, to clothing, shelter and meeting those needs and ultimately graduating them from the program with an established primary care provider to manage their ongoing medical concerns for

00:19:31:15 - 00:19:43:21
Dr. Johnna Nynas
the rest of their lives. And that's the work that takes a lot of time and effort in the short term. But the long term game is what's going to really move that needle in terms of maternal outcomes overall.

00:19:43:24 - 00:20:05:20
Julia Resnick
Absolutely. So as we wrap up, I want us to look forward towards the future and thinking about what are some things that our hospitals and health care systems should consider doing when serving pregnant and postpartum Indigenous individuals. So, Dr. Pattara-Lau, I'll ask you to answer that from the national perspective. And Dr. Nynas I'll ask you to address that from your hospital community's perspective.

00:20:05:22 - 00:20:08:03
Julia Resnick
Dr. Pattara-Lau, I'll start with you.

00:20:08:05 - 00:20:28:22
Dr. Tina Pattara-Lau
So at the national level, in response to the closure of rural labor and delivery units and the decline in birth national birth volumes, IHS has developed an obstetric readiness in the emergency department. We're calling it OB-Red, for short, manual and training programs. This is a collaborative, multidisciplinary team effort across our service areas Phenix, Navajo, Great Plains.

00:20:28:22 - 00:20:49:02
Dr. Tina Pattara-Lau
And we actually had some input from Alaska. We're fortunate enough to travel to South Dakota recently to provide some on new ground training as well. It provides a site, some maternity care deserts where an OB provider is not readily available with readiness checklists, quick reference protocols and training curriculum essentially for safe triage, stabilization, transfer of pregnant patients and newborns.

00:20:49:04 - 00:21:16:01
Dr. Tina Pattara-Lau
And so, as I mentioned, several IHS areas have implemented O.B. Red and demonstrated increased confidence with both triaging management of patients and newborns. We're also working as well to increase access to care during that critical pregnancy and postpartum transition period by piloting a maternity care coordinator program or MCC. And similar to what Dr. Nynas described, this is really an way to utilize telehealth and home visitation support, some of which does exist.

00:21:16:04 - 00:21:46:18
Dr. Tina Pattara-Lau
Alaska is a great example in the interior. Utilizing StarLink, we're able to increase broadband access. While not perfect, but certainly increases the amount of specialty care that you can get into the rural space. And really utilizing those approaches to increase screening education intervention, including the distribution of self-monitoring blood pressure cuffs, which we know can often save patients the time to schedule an appointment or obtain child care, gas for the car and then transport themselves to the clinic.

00:21:46:20 - 00:22:08:25
Dr. Tina Pattara-Lau
During the pandemic, we also expanded our virtual echo curriculum, which was a vital way for us to essentially reach providers across IHS to provide continuing education, but also specialty consultation. And we'll be partnering with the Northwest Portland Area Indian Health Board to launch a monthly Indian country, Echo on care and access for pregnant persons. And our goal is to bridge traditional practice with evidence based care models.

00:22:08:28 - 00:22:30:19
Dr. Tina Pattara-Lau
So our first webinar will highlight the work of one of our first Indigenous midwives and teachers. And so we invite you and your listeners to visit our website, newly launched with last month. www.ihs.gov/ach and to learn more about resources available for American-Indian, Alaska, Native communities and the people who provide care for them. So thank you again for the opportunity to share with you today.

00:22:30:19 - 00:22:33:06
Dr. Tina Pattara-Lau
And thank you to Dr. Nynas as well for the work that you do.

00:22:33:06 - 00:22:38:13
Julia Resnick
That’s wonderful. Dr. Nynas, turning to you for some final thoughts.

00:22:38:15 - 00:23:05:13
Dr. Johnna Nynas
Yeah, we're piggybacking on that exact same work. We are hoping to launch what we're calling an OB virtual hospitalist program to bring kind of a telemedicine view similar to telestroke into our regional EHRs to support those local providers in stabilization and assessment in an emergency situation, because I can't function as a successful OB-GYN if I don't have a provider who can successfully stabilize a patient prior to our transfer.

00:23:05:14 - 00:23:37:15
Dr. Johnna Nynas
So thank you for all the work that you're doing, Dr. Pattara-Lau, it's wonderful. In thinking about how to move forward for communities, I think really important part of this is improving our knowledge and understanding of trauma, informed care and implicit bias training for your team. I think that is a really critical part, not only to acknowledge the historical trauma and the disparities that exist within our community, but to move forward with it from a place of humility and trying to understand those barriers and respond to them appropriately.

00:23:37:15 - 00:24:06:13
Dr. Johnna Nynas
So I think that's really critical for hospital systems to consider. I would also encourage health care providers and hospital systems to really look within their own regions and communities and who else is providing this work and really working to form those collaborative relationships within your region. And they're going to look different place to place. But the more that you develop that collaborative team and that strong relationship and promote referrals back and forth between agencies.

00:24:06:16 - 00:24:24:03
Dr. Johnna Nynas
I would encourage meetings face to face, if you can, at least a couple of times a year to keep each other informed. But that has been really critical in trying to move the needle in terms of outcomes and connect patients to the right resources in care. And you can't do that unless we know what's out there and what everyone's trying to do without recreating the wheel.

00:24:24:06 - 00:24:45:21
Dr. Johnna Nynas
And then the other thing that I really learned throughout this process is we need to stop the the mindset of we're trying to solve this problem right now. And that's happening today. What we're trying to do is set the foundation of what our options to sustain this care for 20 years. What do I want the outcomes to look like 30 years from now?

00:24:45:21 - 00:25:08:11
Dr. Johnna Nynas
What is this going to look like in seven generations? Because that's really the changes we want to make is really improve the health of our communities over time. So we're really trying to think about this is what should this look like 50 years from now down the road to support women and birthing persons and also that culture. So I think really having that forward thinking mindset is really critical.

00:25:08:13 - 00:25:34:12
Julia Resnick
Absolutely and I think that's a big part of why we're here to build that foundation so that over the next years, months, years, generations ahead, we can provide better care for our American Indian and Alaska Native pregnant people. So I want to thank you, Dr. Pattara-Lau and Dr. Nynas for your time for sharing your expertise and insights and for all the work that you are doing to improve outcomes for indigenous moms in your communities.

00:25:34:15 - 00:26:00:17
Julia Resnick
And to our listeners, you've heard us mention a few different resources over the past few minutes. So I encourage you to visit CDC’s Hear Her campaign specific for America Indian and Alaska Native Communities. The campaign offers educational information and tools for pregnant and postpartum indigenous women, their partners, friends and families, and for health care providers as well. You also heard us mention HRSA's National Maternal Mental Health Hotline.

00:26:00:19 - 00:26:10:06
Julia Resnick
Again, that number is 1-833-TLC-MAMA. So thank you again to both of you for joining us and your expertise. And to all of you for listening in.

00;00;01;01 - 00;00;39;09
Tom Haederle
Some 57 million rural Americans - about 17% of our population - depend on their hospital as an important source of care, as well as a critical pillar of their area's economic and social fabric. As we observe National Rural Health Day on November 16th this year, now is a good time to take stock of the stresses and challenges that continue to confront rural care providers, but also to explore some trends, creative ideas and new approaches to help rural hospitals and health systems continue to provide the essential services that patients rely on.

00;00;39;11 - 00;01;11;17
Tom Haederle
Welcome to Community Cornerstones. Conversations with Rural Hospitals in America. I'm Tom Haederle with AHA Communications. In today's podcast, two senior health care leaders with years of experience serving rural populations take a deeper dive into the future of rural hospitals and health systems in the U.S. Host Michelle Hood is executive vice president and chief operating officer of the AHA, and her guest, Dr. Joanne Conroy is president and CEO of Dartmouth Health in New Hampshire, as well as chair elect of the AHA Board of Trustees.

00;01;11;19 - 00;01;17;18
Tom Haederle
Dartmouth Health, by the way, is the most rural academic medical center in the country. Let's join them.

00;01;17;20 - 00;01;41;03
Michelle Hood
Good day. My name is Michelle Hood, and I have the pleasure of serving as the executive vice president and chief operating officer of the American Hospital Association. Joining me today is Dr. Joanne Conroy, president and CEO of Dartmouth Health and chair elect of the AHA Board of Trustees. We are here to discuss the future of rural hospitals and health systems.

00;01;41;05 - 00;02;09;01
Michelle Hood
But first, let us establish our rural credentials. Nobody disputes that Maine is a rural state. In fact, some of the state is designated frontier. As the former president and CEO of Eastern Maine Health Care, now Northern Light Health, headquartered in Brewer, Maine, I worked with and on behalf of rural hospitals, including critical access hospitals that were system members across the entire state.

00;02;09;03 - 00;02;22;01
Michelle Hood
Likewise, nobody disputes that New Hampshire is a rural state. Dr. Conroy, you also are familiar with rural health care as both a clinician and administrator. Please share with us your rural credentials.

00;02;22;03 - 00;02;43;13
Joanne Conroy
Well, I started my career in South Carolina, which at least from the Medical University of South Carolina we took care of a number of people in both rural South Carolina as well as Georgia. And since 2017, I've had the pleasure of being president and CEO of Dartmouth Health, which is the most rural academic medical center in the country.

00;02;43;15 - 00;03;02;12
Joanne Conroy
And not only have I had an appreciation about how rural New Hampshire, Maine and Vermont are, but also the fact that our relationship with our rural partners is shifting dramatically during COVID. And you can see the future change even more.

00;03;02;15 - 00;03;23;15
Michelle Hood
For those listening, just know that meeting rural challenges and opportunities is near and dear to both of our hearts. Our commitment to those providing care to those living in rural America is steadfast. Dr. Conroy, please share with us some of what is unique about Dartmouth Health and how you are working to meet the challenges of rural health care.

00;03;23;18 - 00;03;50;28
Joanne Conroy
Historically, academic medical centers depended on creating a network of hospitals to deliver a volume of patients to their facility created this inflow. But what Dartmouth Health has been trying to do is create an outflow, meaning to direct patients to receive care in their community and or go to those specific community hospitals where we've established the expertise to give patients care

00;03;50;28 - 00;04;14;11
Joanne Conroy
close to home. That's a little bit of a different model than we've had historically with an academic medical center seated within a network of facilities. I have to say that COVID actually accelerated this, but it was already part of our plan, which was everything didn't need to come to the academic medical center. Only those really high acuity patient care issues.

00;04;14;14 - 00;04;15;25
Michelle Hood
Meet people where they are.

00;04;15;28 - 00;04;41;12
Joanne Conroy
That's right. And I have to say that we have really a deep appreciation for what those communities actually are doing. All health care is local and there's no anonymity. So when I'm in Hanover, we solve our problems in all three of the co-op. But if I'm in Keene and I'm visiting Cheshire Medical Center, I have the same level of recognition from the people in the community as I do up in Hanover.

00;04;41;12 - 00;04;46;16
Joanne Conroy
And it's just a broad footprint that you learn to appreciate and value.

00;04;46;18 - 00;05;05;05
Michelle Hood
Yeah, love it. I couldn't fill up my car with gas without somebody coming to talk to me about their latest experience with the health care system. So, you know, we're getting ready to come out of this public health emergency May 11. It is officially over. So what do you see as some of the greatest challenges as we enter this new phase?

00;05;05;07 - 00;05;32;04
Joanne Conroy
Well, there are a lot of things the American Hospital Association has advocated for that are going to help us, even though the PHE actually sunsets. They have managed to extend some of the telehealth provisions. But there are other things that are happening coincident with the public health emergency sunsetting that cause me some concern. The federal government had talked about moving people off Medicaid.

00;05;32;11 - 00;05;58;01
Joanne Conroy
I find that incredibly concerning. Certainly our rural patients, the number of people that actually are have bankruptcy from medical debt is actually been decreasing because we've expanded Medicaid and yet we're going to reverse a lot of that as states, and this is a state decision, decides whether or not to move people off their Medicaid rolls. That creates incredible challenges for rural America.

00;05;58;02 - 00;06;16;21
Joanne Conroy
And we forget that there's tremendous poverty in a lot of our rural geographies. And along with poverty, affordable health care is a component of it. It's not the entire solution, but it certainly is a lifeline for a lot of those families and patients and certainly the communities.

00;06;16;28 - 00;06;48;11
Michelle Hood
Yeah, for sure. So I know that you're very familiar with the AHA strategic plan that we're currently in year two of a three year plan. Our key priorities are providing better care and greater value, advocating for the financial stability of hospitals and health systems. Everybody's number one concern addressing workforce challenges and designing strategies to support our members. And in that work across the U.S.

00;06;48;14 - 00;07;11;02
Michelle Hood
Enhancing innovation, especially as it relates to meeting consumer demands and changing consumer demands, and then finally rebuilding and enhancing public trust and confidence in America's health care system. So it's a flexible but broad strategic plan. And how do you see that aligning with the needs of rural hospitals and health systems?

00;07;11;04 - 00;07;39;25
Joanne Conroy
Let's talk about workforce first. That's what keeps most people up at night. And rural geographies have a greater challenge than urban geographies. We simply don't have the available workforce to recruit. New Hampshire has the lowest unemployment in the country. And on top of that, the geographies are a lot more attractive for people to live in the southern part of the state, where we have over 600,000 people in New Hampshire on the seacoast. And then the rest of the state is relatively rural.

00;07;39;25 - 00;08;03;27
Joanne Conroy
So how do you recruit people to those areas of the state that need that workforce? And then how do you retain them? It's interesting. Most rural communities are now talking about their big issue is housing and affordable housing for their employees. You know, our roles have changed in communities. We can no longer actually limit our involvement to the walls of our facility.

00;08;03;27 - 00;08;30;19
Joanne Conroy
We actually have to get out into the community and be very, very involved. And we've led an effort that's focused on vital communities in the Upper Valley in New Hampshire, where we are creating a low interest investment fund so developers can come in and build single family homes because we know that's the pathway for the future. So workforce is rough across the country, but it's really bad in rural geographies.

00;08;30;22 - 00;08;56;10
Joanne Conroy
I would say the second aspect that we need to consider is the fact that what works in urban and suburban geographies does not work in rural health care. Most of our value based programs do not work in rural health care. There are so many different obstacles, like if I want to do a hospital at home, it's six miles down a gravel road and they don't really have a reliable internet and sometimes not reliable electricity.

00;08;56;12 - 00;09;04;27
Joanne Conroy
So creating a hospital at home is far easier when your hospital at home geography might be five miles. You know.

00;09;05;00 - 00;09;07;01
Michelle Hood
With good broadband.

00;09;07;04 - 00;09;13;24
Joanne Conroy
Broadband. So I think people think that everything is easily translatable, but it's actually not.

00;09;13;26 - 00;09;44;25
Michelle Hood
I think that's the power of the work that we're doing with our members and the board in particular around trying to find different pathways to the future. I mean, maybe that future will intersect at some point, but we all are going to have different ways of getting there. Last thing I wanted to talk to you about is that, you know, our mutual and shared interest in advocating for women leaders and there are quite a few women CEOs in rural health care and beyond.

00;09;44;27 - 00;10;00;20
Michelle Hood
And I know that you're a founding member of Women of Impact and have worked to increase the leadership opportunities for women in health care. So how do you see our ability to collectively open more doors for women leaders?

00;10;00;22 - 00;10;24;10
Joanne Conroy
So first of all, I start with the data, is that we've got 15 years of data across Fortune 500 companies that when you have a diverse leadership teams and diverse boards, you make better decisions. So there's plenty of evidence to say that we should invest in creating diverse teams. And part of diversity is gender diversity. As we track the increase in women leaders across the country, you know, it's going to take

00;10;24;14 - 00;10;26;22
Michelle Hood
100 years to see parity in the C-suite.

00;10;26;22 - 00;10;53;18
Joanne Conroy
So we've got a lot of work ahead of us. I would say that hospitals and health systems need to think about a couple of things. Number one, investing in leadership programs for women. KPMG has actually done that quite successfully. Invest in them. They will pay you back in multiples. The second thing is make sure you create career paths for women and that there is an element of sponsorship within your organization.

00;10;53;22 - 00;11;15;06
Joanne Conroy
Even if you sponsor a woman and that means put her name forward at an organization outside of your system, you are still advancing that individual's career and it helps all of us. Those are things that I think are really important, and I get the pushback from a lot of my male colleagues. They say, well, why are you doing something for women?

00;11;15;06 - 00;11;29;05
Joanne Conroy
Why don't you do it for men? I said, listen, when we have parity, we can talk about equal balance of programs. But right now we've got 100 years where we need to catch up. And so let's not argue about how we do it. Let's just start doing it.

00;11;29;10 - 00;11;57;16
Michelle Hood
Yeah, that's great. So I want to thank Dr. Conroy. I thank you for sharing your thoughts on the future of rural hospitals and health systems and and lastly, the challenges that must be overcome to assure a viable and robust rural health care delivery system. And also, of course, share your passion around advancing women in health care leadership. I know our listeners appreciate the credibility that you bring through a lifetime of experience as a physician and leader in rural health care.

00;11;57;19 - 00;12;03;05
Michelle Hood
I am Michelle Hood, EVP and CEO of the American Hospital Association. Thank you for listening.

00;12;03;11 - 00;12;04;01
Joanne Conroy
Thank you, Michelle.

00;00;00;21 - 00;00;22;27
Tom Haederle
Nearly 20% of Americans rely on rural hospitals and health systems as the sole provider of their health care needs. An important regulatory step taken at the start of this year has expanded the scope of services that rural providers can offer. Stay with us to learn more about this welcome step forward and how it's working out so far.

00;00;22;29 - 00;00;48;06
Tom Haederle
Welcome to Community Cornerstones Conversations with Rural Hospitals in America. I'm Tom Haederle with AHA Communications. Rural Emergency Hospitals officially became a new type of care provider on January 1st, 2023. The new designation means that for the first time, Medicare will pay for emergency department and other outpatient services without requiring the facility to meet the current definition of a hospital.

00;00;48;08 - 00;01;08;05
Tom Haederle
In today's podcast, John Supplitt, senior director of AHA Rural Health Services, speaks with a hospital CEO and a public policy expert, from New Mexico and Michigan respectively, about what's involved in converting to and meeting the eligibility requirements of a rural emergency hospital and what patients stand to gain from it.

00;01;08;07 - 00;01;34;13
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico. And Laura Appel, executive vice president of government relations and public policy at the Michigan Health and Hospital Association. And we're here to discuss rural emergency hospitals and its evolution as a new model of payment and delivery.

00;01;34;15 - 00;02;10;14
John Supplitt
Welcome, Christina and Laura. It's great to have you on our podcast. So effective January 1st of 2023, rural emergency hospitals are a new provider type and it allows Medicare to pay for emergency department and other hospital outpatient services in rural areas without requiring the facility to meet the current Medicare definition of a hospital. You each are bringing a unique and important perspective to the formation of rural emergency hospitals, and I want to set a baseline for our listeners regarding your interest in this opportunity.

00;02;10;16 - 00;02;41;20
John Supplitt
And first, Christina, you are a CEO of a ten-bed sole community hospital in eastern New Mexico on the Pecos River, midway between Albuquerque and the Texas border. It's also where Interstate 40 historic U.S. Route 66 and two other federal highways converge. And you are the only hospital for more than 4500 people living in an area of 3000 square miles. And the topography, high plains and natural lakes.

00;02;41;27 - 00;02;44;03
John Supplitt
So you are out there, you're remote.

00;02;44;05 - 00;02;55;26
Christina Campos
Yeah, we're about 60, 65 miles from the nearest hospital. And it's not a hospital that has a higher level of care. It's similar care. So for advanced care, you already have to drive 120 miles.

00;02;55;29 - 00;03;08;18
John Supplitt
It's significant and I think people get the picture. So what does the community expect from Guadalupe County Hospital and what are the challenges you face as an acute care hospital in this unique setting?

00;03;08;22 - 00;03;30;08
Christina Campos
Yeah, well, interestingly, acute care worked for us. Sole community hospital, our hospital specific rate worked for us for the last 20 years. It's no longer working for us and we know that critical access reimbursement will not work for us. It would be less than what our rate has been, but our community expects us to provide life saving care.

00;03;30;11 - 00;03;53;07
Christina Campos
And I think in the years that I've been involved with the AHA and with one of the original task force for ensuring access to vulnerable communities, and we kind of surveyed the field to see what does that mean. Emergency care was at the top of the list and inpatient care was not. But the money was in inpatient care and our ED was a loss leader.

00;03;53;14 - 00;03;53;23
John Supplitt
Right.

00;03;53;24 - 00;04;19;20
Christina Campos
So being able to come up with a new designation, a new model of care and reimbursement that actually fits the way we are providing care, especially as we get better at chronic care management and preventive care and start really reducing the need for inpatient care. We've been working on reducing readmissions and for years I teased we're committing a slow suicide as a hospital.

00;04;19;22 - 00;04;23;13
Christina Campos
This is a lifeline that is being thrown out to my hospital.

00;04;23;15 - 00;04;51;21
John Supplitt
Yeah. Yeah, it's interesting. I mean, the concept of a rural emergency hospital has been around probably since 2016, if I'm not mistaken. And now that it has gotten traction, it's been legislated and codified, it's an opportunity that you really can consider seriously. Now, Laura, for this new model to take effect, states have to have in place legislation that will allow the licensing, certification and payment of this new provider type and service.

00;04;51;23 - 00;05;03;04
John Supplitt
And Michigan was among the first four states to pass enabling legislation. Please share with us why this is a priority in your state and how it came to pass.

00;05;03;05 - 00;05;32;07
Laura Appel
Sure. Like you just mentioned, John, this concept has been around for quite a while and we've been paying attention to it all along for the reasons that Christina mentioned. Eliminating inpatient utilization was important because we were recognizing that that was the way to go with health care. At the same time, the reimbursement model just wasn't following that. So we've been informally asking our members, you know, how does this look to you?

00;05;32;07 - 00;05;56;05
Laura Appel
What might you do with this? And then when it became a reality, probably like many other states, we had at least one member for whom this was financially significant to get this done and started right away. And so we moved on this to get this legislation done last session and have it be signed by the governor asap so that we could jump on it.

00;05;56;07 - 00;06;02;08
Laura Appel
And we are assisting a member in particular to move forward with this as quickly as possible.

00;06;02;13 - 00;06;04;04
John Supplitt
That was a really aggressive timeline.

00;06;04;06 - 00;06;27;19
Laura Appel
Very aggressive timeline. And in Michigan in particular, our Certificate of Need program, it does not allow for what the federal statute allows for essentially banking your beds and having a do over, if you say within the first five years, this doesn't work for us. That was not allowed in Michigan statute in any way. And the way our certificate of need works, we don't have any designated bed need.

00;06;27;21 - 00;06;40;04
Laura Appel
So there was no going back if we didn't get that law change and we really needed to do that. We also didn't have a mechanism for a licensure provision for a rural emergency hospital, and we had to create that as well.

00;06;40;05 - 00;07;08;23
John Supplitt
Right. So let's fast forward now to November of 2022. CMS has finalized the roll emergency hospital conditions of permit participation and the payment rates that will apply to the emergency department and hospital outpatients services in connection with the 2023 hospital outpatient PPS final rule. So then in January of this year, CMS published guidance on this rulemaking and you've both seen and read the CMS rule and the guidance.

00;07;08;25 - 00;07;23;02
John Supplitt
The question I have is, is it what you expected? And can you work within this framework? And Laura, let's start with you. Was the final rule in January guidance what you expected? And is this a framework in which you can work?

00;07;23;03 - 00;07;45;22
Laura Appel
Yeah. I'm going to say generally we can work with this, of course. And I'm sure that Christina will have a comment on this as well. You know, to not have these types of hospitals eligible for 340B makes the financial calculation much more complex, I think. The other thing that we're very disappointed in is the opportunity for swing beds.

00;07;45;25 - 00;08;24;17
Laura Appel
We had many more opportunities to think about how to use swing beds during the recent pandemic, and we are particularly interested, we're very much looking at the example of what they've been doing at Dayton General Hospital in southeastern Washington State. They're using their swing beds for substance use disorder and other complex patients, people that need skilled nursing facilities, but also have the problems of mental illness or, you know, general difficulties of anxiety and other things, things that make it very difficult for us to place those patients in nursing and other nursing home settings.

00;08;24;23 - 00;08;31;19
Laura Appel
And we need that flexibility. And so to not have that be a part of the program, that's a disappointment.

00;08;31;21 - 00;08;55;17
John Supplitt
Well, and I think you bring up something that's really important, that's flexibility. And the limitation of a statute that codified rural emergency hospitals doesn't allow for a lot of flexibility. And as much as we have commented and tried to reach some sort of accommodations through CMS, there's only so much that they can do. So it remains a work in progress without a doubt.

00;08;55;20 - 00;09;03;00
John Supplitt
But Christina, the same question then: Was the CMS guidance what you expected and can you work within this framework?

00;09;03;07 - 00;09;21;29
Christina Campos
Well, you know, ironically, you would think that the transition would actually be easier for a critical access hospital than for an acute care hospital, but it's not. Critical access hospitals have been giving certain leeway with the swing beds where it's reimbursed on a cost basis. I don't have a swing bed at my facility because the equation wasn't good.

00;09;21;29 - 00;09;44;28
Christina Campos
It didn't work for us. So I'm not giving up swing beds. Interestingly, I don't have 340B either because in my community the primary care center is a partner. But a separate organization. So they are the 340B provider and my pharmacy at the hospital is A 340B pharmacy. So I do have an interest in it, but I am not prohibited from that aspect of it.

00;09;44;29 - 00;09;46;18
John Supplitt
Well, that's very unique.

00;09;46;20 - 00;10;14;07
Christina Campos
So I'm not losing funds for 340B, I'm not losing funds for SNF or for swing beds and having to become a SNF, which is cost prohibitive, I think. And then you have to have two administrative, separate entities. So I think for me in particular, it's a really, really great fit. But I do recognize that many of the other hospitals in New Mexico, the math doesn't quite work out for them because they are losing swing bids and because they are losing that 340B money. for

00;10;14;07 - 00;10;33;02
Christina Campos
So I think this might be a foot in the door. Yeah, but there's going to have to be a lot of work done to make it a viable option for many, many more hospitals. Right. In terms of the legislative process, New Mexico was not ready. I think my hospital is the one that put it on the radar for the state and said, hey, this came up.

00;10;33;04 - 00;10;51;27
Christina Campos
We looked at it in October. Our state hospital association put out the cost analysis for us. And, you know, when I saw what the base payment was, we did the math right away and says, this works for us. This will work for us. To date this year, we've lost already $1.8 million under our current structure. This will make up that difference.

00;10;51;28 - 00;11;18;16
Christina Campos
Wow. And we're also comparing current to pre-pandemic and the numbers that came out were pre-pandemic. So the difference is huge. But my state was not ready and my legislature was not going to go into session until January. It ended in March. So I spent, you know, a good amount of the last two months prior to April in Santa Fe advocating this was very much my bill.

00;11;18;18 - 00;11;40;07
Christina Campos
It was signed just a couple of weeks ago on on Good Friday, which made it a very good Friday. And it does not go into effect until June 16th because it did not have an emergency clause in it. However, even that makes sense for me. We're we're financially stable. We're okay. We're losing money now. But we knew that the day was coming and we had saved for it.

00;11;40;09 - 00;11;57;05
Christina Campos
But we're going to be able to become an REH on July 1st, which is going to be great because we're not going to do two separate cost reports or a cost report structure based on one payment mechanism. And then in half of the year or portion of the year based on the other. But the timing was weird. The timing was weird.

00;11;57;07 - 00;12;04;07
John Supplitt
But that's very exciting news then. So congratulations on getting the legislation passed. And so now you're going to hit the ground running on July one.

00;12;04;08 - 00;12;04;23
Christina Campos
July one. 00;12;04;23 - 00;12;05;13 John Supplitt Exciting.

00;12;05;16 - 00;12;09;20
Laura Appel
Yeah, it makes me grateful to have a full time legislature.

00;12;09;22 - 00;12;10;17
Christina Campos
Yeah, right.

00;12;10;18 - 00;12;14;04
Laura Appel
Not always, but in this case, it was good luck.

00;12;14;06 - 00;12;37;24
John Supplitt
Well, and of course, the payment, as you both have mentioned, has been a major focus of the providers and policymakers regarding the viability of rural emergency hospitals. And to review, CMS is going to pay an additional 5% over the payment rate for the hospital outpatient prospective payment for REH services. And they'll also pay an additional annual facility payment in 12 monthly installments.

00;12;37;26 - 00;12;59;17
John Supplitt
And for 2023, that monthly payment is $272,000 and change. So for 2024 and each year after then it will increase by the hospital's market basket percentage increase. So the question is, Christina, and you may have answered this, but we'll ask it again, will this payment be sufficient for you to maintain services in your communities as an REH?

00;12;59;25 - 00;13;19;08
Christina Campos
Yeah, you know, when they first started talking about the REH concept and they were the only thing they identified at that time was that 5% increase in patient services that wasn't going to do it for me. It absolutely was not. As a sole community hospital, we were already getting about us. I believe our cost report prepared. So it was somewhere about a 7.5% add on.

00;13;19;10 - 00;13;39;02
Christina Campos
So we're going to forfeit that by a couple of percentage points. But when we got that number and it was a little bit lower when it first came out in October and then it was adjusted because of low volume adjustments and other mathematical equations that went to it. It's $3,274,000. And I mean, I know the amount because I've had to apply it and reapply it.

00;13;39;03 - 00;13;59;12
Christina Campos
We just finished our preliminary budget, which will be hopefully approved at my board meeting next week. This week, in fact. And it's not going to show us, we're not going to be rich off of this. We're absolutely not going to be rich off this. We're going to have a positive margin, very slim, positive margin, which is, you know, de facto for all rural hospitals, but a survivable margin.

00;13;59;12 - 00;14;20;02
Christina Campos
And then we'll work on expanding outpatient services for our community in a wise way that will hopefully improve margins over time. But we're going to be able to quit concentrating on our lowest volume of services, which was inpatient and concentrate on our high volume, which is outpatient and emergency department services.

00;14;20;05 - 00;14;52;18
John Supplitt
I want to dive into something that you brought up and that was the involvement of your board. So you're a county hospital and so you have a public board, and so you've been working with them for the better course of two years, almost two years to try to condition them towards this conversion. Help us understand what that experience has been like from the moment where you started to consider this transition to rural emergency to the point now where you're actually going to approve a budget that will go into effect July one?

00;14;52;20 - 00;15;20;08
Christina Campos
Well, you know, at first when when the concept of REH, I was not paying attention to it because I didn't know what the base payment was. And that made all the difference. So I kind of ignored it. You know, it was it was on my radar, but it didn't seem to be the solution for us. And when those numbers first came out in in, you know, August, you know, early early numbers came out, and then when the final number came out in November, we did have a board retreat and discussed with the board, this is an opportunity for us to do it.

00;15;20;10 - 00;15;49;16
Christina Campos
And in fact, you know, when people say, what about the transition? Well, it's not. We've been transitioning into this over the last four or five years easily. Our inpatient census is almost nothing. Even our length of stay because of the quality of care that's given on the outpatient services, because of the quality of care, even on an inpatient service, that you can get your normal rural admissions like COPD, pneumonias, everything that's treated medically because we don't have surgical services.

00;15;49;19 - 00;16;13;12
Christina Campos
We're struggling to keep them a second midnight because people are turning around so much more quickly. Mm hmm. So the transition is really a financial transition, a document transition. Semantics. So even discussing it with my board, it's the same conversation that we're having with the community. We're really not changing our clinical way of providing care. We've already done this.

00;16;13;14 - 00;16;27;13
Christina Campos
We're going to change the way we build and the way we're reimbursed. But the same high level of quality of care will stay still in effect, and patients, rather than being admitted, will be opposed. So we're just going to be billing part B instead of part A.

00;16;27;15 - 00;16;52;29
John Supplitt
Well, and let me pull that thread a little bit, too, because CMS has also established rules regarding access, safety and quality of care for rural emergency hospitals. And they closely align with critical access and ambulatory surgical centers but you're a sole community PPS. Among these requirements is a quality assessment and performance improvement program. So Cristina, do you see any challenges in meeting these requirements upon conversion to an REH?

00;16;52;29 - 00;17;14;29
Christina Campos
Do you know what I see as a challenge is that people are going to assume that we can be lax because we were already having to do HCAPS, we are already having to do all the quality measures, you know, compared the same ones that the huge hospitals were doing on a micro level with a ten-bed hospital. So what I'm telling my employers that we are not going to change the quality of care, we're not going to do HCAPS anymore.

00;17;15;06 - 00;17;37;03
Christina Campos
We're going to ED CAPS. We're still going to have the same measures in terms of of, you know, diabetic patients that are kept overnight or re managing that carefully or hospital acquired infections, everything else. But we'll document a little bit differently. We're still going to want a care plan because patients might stay one night, maybe two nights on the off chance.

00;17;37;06 - 00;17;49;17
Christina Campos
So I'm going to be challenged and making sure that we keep that same high level quality care and know that we are going to be just as as scrutinized, if not more so, than we were as an acute care hospital.

00;17;49;20 - 00;18;10;13
John Supplitt
Those are really great insights. Thanks for sharing there. So Laura, given what we know about the REH payment and rules for quality assurance and patient safety, do you foresee hospitals in Michigan moving towards this new model of payment delivery? That is, do you anticipate critical access hospitals or others converting to a rural emergency hospital?

00;18;10;16 - 00;18;42;12
Laura Appel
This is such a different question now than it was three years ago. I think that this was really anticipated for a while. Again, you mentioned that this was a conversation starting in 2016, but during the pandemic, I do not know of a hospital in Michigan that didn't have a sizable number of inpatients compared to their bed availability. Everybody had a high census. Places that had a four patient census average census places had two.

00;18;42;14 - 00;19;02;20
Laura Appel
All of a sudden they were full or maybe they were at, you know, 70%. Things that had been unheard of in the past. And that just so changes your frame of reference. It's so hard now to look around for some people and say, Yeah, we were transitioning away from that and we can return back to that mindset and think about REH and that mechanism.

00;19;02;22 - 00;19;33;22
Laura Appel
We are seeing people shifting back to that, but it was not, you know, when when the bill was signed and even last year when you were saying that the first numbers came out, there were few organizations that would say, Yeah, we might have somebody for that, but really very little objective interest in it. And now I'm just now starting to see compared to, I would have thought five or maybe even ten critical access hospitals would've been absolute candidates for this.

00;19;33;25 - 00;19;56;13
Laura Appel
I think the the thing that really appeals to me about it is: there's no secret about it, Michigan has lost population in our rural areas. The prediction is we will continue to lose population, but our population that remains there will be older. So we will have a group of people who really do need services at the same time that we don't have that many people to spread the cost over.

00;19;56;14 - 00;20;23;03
Laura Appel
So we have these fixed costs that are required to keep an ED open and to have those observation services. And yet at the same time we, you know, you can't make it up on volume when you just don't have very much volume there. So I think that the model of having those fixed payments is so important. And again, we're told all the time hospitals and health care need to become much more innovative, but the payment policy almost never kept up with it.

00;20;23;09 - 00;20;27;19
Laura Appel
I really see this as being a step in the right direction by the the federal government.

00;20;27;20 - 00;20;52;17
John Supplitt
Well, it really is fascinating to see how the landscape has changed, as I call it, in ways that we might have not have anticipated. But now, as we're learning more how these opportunities might still be important to rural hospitals. Well, my last question, Laura, we'll start with you. What opportunity does conversion to rural emergency hospital mean to your hospitals and the rural residents in Michigan?

00;20;52;19 - 00;21;20;19
Laura Appel
Well, we don't have the same landmass as some of the super large states like Texas or Alaska. But the Upper Peninsula, for example, is very large and only has 300,000 people in it. And we really need to be able to have a number of different facilities spread across that area. And yet you just don't have enough people to support it at the rates that are currently paid.

00;21;20;21 - 00;21;43;25
Laura Appel
And I understand why folks don't want to see higher payment rates necessarily, but you can only drive down the fixed costs so far. We really do need emergency services spread across our state and that includes our rural areas. Our rural residents serve that kind of health care just as much as the people in our suburban and urban areas.

00;21;43;28 - 00;22;12;12
Laura Appel
So I think over time, this is going to become a much more popular model and it is going to keep access to the most vital, emergent and typically used health care services. Like Christina said, already folks drive if you need cancer care or bypass surgery or things like that. We're already driving for those services anyway. But this is going to keep those emergency services much closer to the community.

00;22;12;12 - 00;22;14;29
Laura Appel
And I'm very excited about that.

00;22;15;01 - 00;22;34;19
John Supplitt
This is a really fantastic discussion. Yeah, this is a work in progress, but there's a lot from which to work and so there is a great deal of hopefulness here. Christina, the same question: What opportunity does conversion of Guadalupe County Hospital to a rural emergency hospital mean to the community from both a medical and economic perspective?

00;22;34;24 - 00;22;53;27
Christina Campos
Do you know this is a survival mechanism. This will allow my hospital to stay open. It will allow us to continue to save lives. You know, we're an incredibly remote area, small population. But as you mentioned at the beginning of the podcast, you know, we've got I-40, we've got Route 66, U.S. 84, U.S. 54 there all converge in that community.

00;22;53;27 - 00;23;12;11
Christina Campos
So a ton of traffic. We do get a lot of motor vehicle accidents. So and we have scuba diving. Go figure. We have scuba diving in our communities. So we do have a lot of lakes. But, you know, without a hospital my community probably would little by little disappear. So it's critically important to the community. There is a lot of work that needs to be done.

00;23;12;11 - 00;23;33;23
Christina Campos
I just found out a week or two ago that my hospital will not qualify for the flex program because it's for hospitals with inpatient services and it's meant for critical access hospitals and small rural hospitals. So that's going to have to be changed, I believe, because these rural emergency hospitals are just a step away from critical access. So there's a lot, a ton work to be done.

00;23;33;23 - 00;23;53;08
Christina Campos
And I really hope that 340B fix is in there and I hope that maybe the possibility of not, you know, maybe a minimal amount of inpatient care. My concern is end of life care. Yeah, other hospitals are not going to take our patients that are that are, you know, facing end of life. We do not have a nursing home in my community.

00;23;53;08 - 00;24;13;12
Christina Campos
We do not have SNF. We do not have, you know, home health care. We have one hospice nurse in the entire county. I need to crack that nut and figure out how we're going to offer that end of life care. And there is flexibility within it because it's a 24 hour average of all of your visits. Most of our E.R. visits are, you know, 3 hours max.

00;24;13;12 - 00;24;32;27
Christina Campos
And that's from the time they walk in to the time they walk out. You average out with all our our so-called inpatient or OBS visits? We're going to stay well beyond that, no matter what. But we want to make sure that we're doing it right and that we offer the care that my citizens and my community, including my family and my neighbors, need.

00;24;32;29 - 00;25;03;04
John Supplitt
Yeah. You know, I can't imagine Santa Rosa or Guadalupe County without a very strong medical presence, given the convergence of three federal highways. So it'll be very interesting to see how this emerges. But I again, I think we all are quite hopeful. I want to thank my guest, Cristina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico, and Laura Appel, executive vice president of government relations and public policy at the Michigan Health and Hospital Association.

00;25;03;07 - 00;25;28;24
John Supplitt
Your perspectives on emergency hospitals as a new model of payment and delivery are very greatly appreciated. And as this model continues to evolve, we will be looking to you and your colleagues for continued insights as to what works and how we can make this model better for patients, hospitals and the communities we serve. I'm John Supplitt, senior director of Rural Health Services at the American Hospital Association.

00;25;28;26 - 00;25;32;17
John Supplitt
Thank you for listening. This has been an Advancing Health podcast.