By Taylor Sisk
The old model no longer worked.
Since 1954, the 52-bed hospital at 500 Morven Rd., on the edge of downtown Wadesboro, county seat of Anson County, had served the community well.
But the model no longer worked for a rural community with a stagnant population. For a variety of reasons, the number of people admitted to small, rural hospitals is declining. All those inpatient beds aren’t needed. The financial model was no longer viable in Anson.
What was needed was something entirely new. But the solution wasn’t immediately apparent. Some reimagining was in order.
“Honestly, I don’t know if we knew what we were getting,” said Denise White, vice president and chief of nursing of the new Carolinas HealthCare System Anson hospital and a leader of the team that planned and designed the one-story facility that now shimmers out on the highway.
There was no existing model. So the Carolinas team created one.
“I think this is the way rural health care is going to go,” said Cody Hand, vice-president for governmental affairs for the North Carolina Hospital Association, of this facility shaped to meet a community’s needs. “I’m impressed by the innovation.”
It took a system to build Anson County’s new hospital – a hospital system with a lot of resources at its avail.
A cardboard model
Anson County is home to some 27,000 residents. In 2012, its overall health ranking was 89th of the state’s 100 counties. Nineteen percent of Ansonians are uninsured.
More than a third of adults in Anson County are obese. Twenty-seven percent have high blood pressure, 21 percent high cholesterol and 17 percent suffer from heart disease.
These are figures that roughly match those of the most underserved of North Carolina’s counties.[pullquote_left]”The county simply could not garner the resources to provide anywhere near what we have now…. We would have been screwed.”[/pullquote_left]In the county’s 2012 community health assessment, 18 percent of those surveyed said a barrier to receiving care was that they had to leave the county for numerous types of care; 14 percent said they had no transportation.
The old hospital, Anson Community, had long been a part of the Carolinas HealthCare System. But Carolinas was, White said, “at a crossroads with what to do in Anson County,” recognizing that to continue to provide health care there, “we’re going to have to do things differently.”
“They came to the board and said, ‘This is what we propose for Anson County,” said Anna Baucom, chair of the Anson County Board of Commissioners. “It was a very detailed plan…. They told us it would be innovative and that it would possibly be a model for rural health care in their whole system.”
Without Carolinas stepping up, she said, “I don’t know what would have happened. Because the county simply could not garner the resources to provide anywhere near what we have now.”
“I don’t know the technical term for it,” Baucom said, “but we would have been screwed.”
The overall objective, said Gary Henderson, the hospital’s administrator, was to improve the county’s health status through a “community-focused care model.”
The first iteration of the new model was fashioned in cardboard – 6,000 pounds of it.
A design team comprised of nurses, physicians, registrars, X-ray technicians and other health care professionals spent five days building, razing and rebuilding a miniature hospital in a warehouse in Charlotte. Cutting, shaping, simulating potential scenarios, designing workflows, “We literally built this building in that space,” White said.
The doors to the life-size Carolinas HealthCare System Anson, a 43,000-square-foot facility built for $20 million, then opened on July 14, 2014.
No more walls
The hospital has two physicians, two nurse practitioners and one physician assistant, and employs a medical home approach to care.
A primary goal was to improve patient flow. To that end, an emergency department nurse and physician assistant screen each patient upon arrival to determine the care required.
“When we did an assessment of the legacy facility, there was a tremendous inappropriate utilization of the [emergency department],” White said. “Only 19 percent of this community had a primary care provider, so the primary care provider was the ED.
“So one of the things we wanted to do was really focus on getting them to the appropriate level of care. We put a lot of work on the front end, on that medical screening exam process.”
There are no walls between the emergency department and primary care. All patient rooms are in one bay, with the staffing stations in the middle.
“The premise behind this is that everything you could possibly do is in this flexible space with a center core for all the support you could possibly need,” White explained.
If a nurse in a primary care room should have a patient experiencing chest pains, “They open the door and say, ‘I need help,’” she said, “and they get an emergency room physician, a respiratory therapist …
“We’re one department serving the needs of the patient.”
There’s a behavioral health specialist on staff, and the hospital offers telepsychiatry.
A ‘healing environment’
A lot of attention was given to the little things.[pullquote_right]Like what you read on NC Health News? Help make it possible. Make a donation today. As little as $10/ month will help keep us going![/pullquote_right]
“We really wanted to put thought into creating a healing environment,” White said. That translates into soothing color schemes, floors with curve and flow in their design, high ceilings and lights throughout that dim.
There are 15 beds in semi-private rooms. But the hospital averages only two or three inpatients a night, with an average stay of 48 to 72 hours, primarily for observation. Acute cases are transported to larger hospitals. There’s a helipad out back.
The hospital has a pharmacy and a payment-assistance program that offers for a small fee meds donated by pharmaceutical companies.
It provides office space for rotating specialists, with a check-in area and exam rooms. It also has a mobile unit that goes out several times a week to churches, schools, Walmart and elsewhere to offer screenings, diagnostics and education.
Should the community grow, the facility is designed such that it can grow with it: an “expandable hospital,” Henderson calls it.
As documented in the county’s health assessment, transportation was a primary concern. There’s no bus or cab service in Anson County. So the hospital offers van service. This is particularly helpful with frequent no-show patients. A patient navigator, provided to help coordinate ongoing care and other resources, takes the initiative in scheduling rides.
Another central tenet is removing departments from silos – a concept reinforced by the absence of walls. Most everyone wears the same uniform. This helps underscore the message that everyone is on the same team.
A great deal of emphasis is placed on skill optimization, “Making sure that we give people the ability to practice at the top of their license or their certification,” White said, “because that’s what people want to do.
“I get really excited about that. I’ve been a nurse a long time.”
Everyone, including the environmental services (housekeeping) staff, is trained in CPR.
And in keeping with its community-focused care model, Henderson said, the hospital is developing a network of community health advocates – in the schools and churches and with the county’s major employers – to serve as “tentacles” to better determine the community’s needs.
The ‘right place’
Carolinas HealthCare System Anson transitioned 2,631 patients into primary care in its first year of operation, people who would have otherwise been seen in the ED.
“They’re at the right place, getting the right care, at the right time,” Henderson said.
The hospital’s patient navigator has assisted 294 patients, many of whose needs were identified in that upfront screening process.
That process, Henderson said, along with Carolinas’ telemedicine services and predictive analysis, are among the reasons the hospital has moved from operating at an average loss of $7,000 a month in the old facility to breaking even and occasionally showing a profit in this new one.
Commissioner Baucom said she heard criticisms from the community early on, which she attributes to the uncertainty of transition, but is hearing a plethora of positive things today.
“We’re excited about the fact that this is groundbreaking,” Baucom said. “And so far it’s working well.”
“The proof will be in the pudding about five years down the road, when we share how we’ve improved the health status of Anson County,” Henderson said.
Meanwhile, the county’s health ranking is inching up, from 89th in 2012 to 84th this year.
But every rural community with an endangered hospital may not have a system such as Carolinas HealthCare to step in.
Asked if something similar could be done without the considerable resources of a hospital system, the Hospital Association’s Cody Hand said, “I know that now that it has been done, it would be easier, because there’s a model. But I don’t know if it would be possible for somebody without the capital that Carolinas has to invest in that sort of location.”
This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.