Rural hospital administrators are recognizing that their foremost responsibilities lie beyond the hospital’s doors.
By Taylor Sisk
There are some 2,000 rural hospitals in the U.S. today, and, one could argue, those hospitals face nearly as many challenges to their viability.
North Carolina’s rural hospital administrators find themselves grappling to gain footing in a shifting economic and health care landscape, pursuing paths they trust will lead to solutions to fit the communities they serve.
And, increasingly, meeting the needs of those communities will require embracing the tenets of “population health.”
Population health is a concept that’s gained currency since the launch of the Affordable Care Act, which ties reimbursement to both individual health results and community health outcomes.
There is no precise definition of population health, but it concerns how health care systems, public health agencies and other community-based organizations need to focus on a wide range of factors including primary and behavioral health care, health literacy, public education, personal responsibility, employment, infrastructure and water quality.
Achieving population health goals requires collaboration across disciplines and new ways of thinking about patient care – efforts that hospital leaders will need to embrace in order to remain relevant, and viable.
Jeff Spade, executive vice president of the North Carolina Hospital Association’s NC Center for Rural Health Innovation and Performance, points out that of the six strategies cited in the North Carolina Institute of Medicine’s 2014 Rural Health Action Plan as being critical to improving the health of rural communities, only two are directly related to doctors, nurses or hospitals. The four other strategies cited address investments in local industry, improving child care and education, support for healthy-eating and active-living initiatives and providing consumers with more information about their insurance options.
But Spade said North Carolina has an advantage: The state has a national reputation as a place where providers already think about care in a system-oriented way.
“We have good, strong, solid health systems, and our rural hospitals, our rural communities, benefit from being part of those health systems,” he said.
N.C. Hospital Association spokeswoman Julie Henry added that another primary factor in advancing this reputation is the support the Kate B. Reynolds Charitable Trust and The Duke Endowment provide for rural health initiatives aimed at broad, population health-based outcomes.
Henry said both are focused on funding alliances that involve “a hospital and other partners in the community or multiple hospitals working together.”
Rural hospital boards, administrators and providers are increasingly aware of the need for such alliances. They’re also aware that keeping people away from the hospital is not only good for the community, it’s good for business.
Rural communities tend to have higher rates of residents who are uninsured, or who have deductibles or co-pays they ultimately can’t afford. They also have higher percentages of patients on Medicare and Medicaid, which reimburse, in general, at lower rates than private insurers.
It pays to keep all of these people as healthy as possible, and it pays to be proactive in the process.
“Our focus, as health care moves forward, is on preventive medicine,” said Fordham Britt, Southeastern Health’s director of physician services. “We want to keep our patients well … keep them out of the hospital.
“Health care is now really in the community.”
Southeastern is based in Robeson County, where the rates of obesity, heart disease and cancer are high and life expectancy is low. Robeson also has the highest poverty rate in the state and one of the highest in the country.
A high percentage of patients at Southeastern’s clinic in the town of Maxton, said office manager Paula McLean, must consider things that most of us don’t have to factor in when weighing our health care options, like “putting gas in the car and having enough left over for that $3 co-pay.”
So Southeastern has clinics located throughout its region with staff that provide essential care, build relationships and educate as best they can.
Dawn Langley, a physician assistant in the Maxton clinic, said many of the medical conditions she routinely encounters are the result of the patient having never been exposed to preventive health services. Meeting her patients’ needs, she said, requires gaining the trust required to allow them to open up.
It’s often not an option, Langley said, to give someone with diabetes an informational brochure or tell them to go online to learn more about their condition. Many of her patients don’t have computers; many are illiterate.
“And they’re hesitant to ask questions because they feel insecure, ashamed, that they can’t read,” Langley said.
Southeastern provides case managers for patients as needed, helping them, for example, find transportation or connect with community-based resources. It also sends staff out to the clinics, on a rotating basis, to assist patients with Medicaid applications.
“It’s really about bringing our health services to the neighborhoods where our patients live,” Britt said, then working closely with social services, the public health department, churches, schools and businesses to leverage all resources within those communities.
Halifax Regional Medical Center in Roanoke Rapids is likewise reaching out into the community to improve health outcomes.
A 2012 community health needs assessment found childhood obesity had risen in Halifax County from 19.1 percent in 2007 to 21.7 percent in 2009. In collaboration with the county health department, the hospital identified six primary population health concerns and found that obesity was a contributing factor to each.
With funding from Kate B. Reynolds, Halifax Regional helped launch a “Get Fit, Stay Fit Roanoke Valley” campaign, a five-year Roanoke Valley Community Health Initiative that involves education, enhancements to local parks, easier access to healthy foods and workplace-wellness activities.
Granville Medical Center in Oxford, a half hour northeast of Durham, offers another model designed toward seamless, community-wide care, one that a number of rural hospital systems are adopting: a transitional care team.
The team coordinates across departments and agencies to help ensure patients who’ve recently been released from the hospital receive the proper follow-up care. This includes information about community-based resources and self-care and a primary care appointment within seven days of discharge.
The objective, said Granville Medical CEO Lee Isley, is to see that patients are “getting the right care in the right place at the right time.”
And as a means of addressing the health care professional recruitment issue cited in the Institute of Medicine’s Rural Health Action Plan, Granville Medical has a professional service arrangement with UNC Rex Healthcare. The agreement provides Granville’s cardiologist, Richard Pacca, with backup support from Rex – colleagues he can consult with and who step in during vacations.
“We would not have been able to recruit the caliber of physician that he is by ourselves,” Isley said. “That’s why we went with a partnership.”
‘Evolving into something different’
Rural hospital administrators are recognizing that in this shifting landscape it’s no longer possible to offer everything. Rather, the key to survival is providing what’s most needed in the community and making provisions to connect patients with what’s not.
More than a third of Transylvania County residents, for example, are over the age of 60, and that number is projected to grow. So Transylvania Regional Hospital administrators chose to offer orthopedics and emergency services but not labor and delivery. Expectant mothers are sent to nearby Mission Hospital in Asheville, with which Transylvania Regional is affiliated.
“None of us wanted to give it up,” said Cathy Landis, the hospital’s president and chief nursing officer. “But at the same time, doing it wasn’t the right thing to do when you don’t do enough of it.”
Landis said hospital administrators are now looking at the entire continuum of health care, not just what happens within their walls.
“That’s going to be the challenge of every Hospital USA,” she said.
It takes a system, the Hospital Association’s Henry said, “to ensure that the services are being offered to support the needs of the community even though the hospital may be evolving into something different.”
She cited Transylvania Regional as an example, and Carolinas HealthCare System’s hospital in Anson County as another. The Anson County hospital provides office space for rotating specialists and has a mobile unit that visits churches, schools and businesses to offer screenings, diagnostics and education.
Hospital staff is also training a network of community health advocates to circulate through churches, schools and the county’s major employers, serving, said Gary Henderson, the hospital’s administrator, as “tentacles” to better assess the community’s needs.
This community-oriented approach to health care, Henry said, “really is a picture of the future,” one that ever more rural hospitals are seeking to emulate.