The Transylvania Regional team. Photo credit: John Warner
The Transylvania Regional team. Photo credit: John Warner

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<p>Transylvania Regional Hospital was selected an iVantage Top 20 Critical Access Hospital. Vital to its success has been that it’s responded to very particular needs in Transylvania County.

By Taylor Sisk

For the third year running, Transylvania Regional Hospital has been selected among iVantage Health Analytics’ Top 20 Critical Access Hospitals in the country, announced by the National Rural Health Association in October. Measures of excellence included cost, quality, outcomes, patient perspectives and financial stability.

This wasn’t the only recent accolade Transylvania Regional has received. In August, Becker’s Hospital Review named Cathy Landis, the hospital’s president and chief nursing officer, as one of its 50 Critical Access Hospital CEOs to Know.

Rural Rx: NC Health News coverage of rural issues. This week, Transylvania and Buncombe Counties.

And the hospital has been nationally ranked for four years as a top performer for quality by The Joint Commission, the leading accreditor of health care organizations in the country.

Transylvania Regional, located just to the southwest of Asheville in Brevard, serves a largely rural area, but it’s a rural community that’s a bit different from most others in the region. The hospital has excelled in this environment by responding to some particular needs, and by evolving with the times.

The same, but different

A not-for-profit founded in 1933, Transylvania Regional was designated a critical access hospital in 2004 and joined the Mission Health system in 2012.

“Critical access hospital” is a designation given by the federal Centers for Medicare and Medicaid Services to some 1,300 hospitals with 25 beds or fewer serving remote areas. It allows those hospitals to receive preferred Medicare reimbursement in exchange for maintaining essential services.

Transylvania Regional Hospital. Photo credit: John Warner

Transylvania County faces many of the same challenges as other largely rural communities in the country: more limited access to health care than in urban areas and a relatively older population and thus more health issues.

While Brevard is only 35 miles from Asheville, “On these mountain roads,” Cathy Landis said, “that distance is longer than it appears,” especially for the elderly.

But while many rural areas find it difficult to recruit doctors and other health care professionals, that’s not the case in Brevard, which rests just beyond the entrance to the Pisgah National Forest and is distinguished as not only a tourist but a retiree destination.

[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]Life isn’t entirely idyllic in Transylvania County: In the first years of the 2000s, three manufacturers (makers of X-ray film, cigarette paper and thread) that were among the primary employers in the community – and that provided their employees with robust health insurance plans – shut down.

This was a blow to the hospital and local health care practices. They now had a lot fewer patients covered by private insurance companies from whom they receive a higher reimbursement than from Medicare and Medicaid. Now only 20 percent of the hospital’s patients have private insurance.

(The hospital had revenues of $66 million in 2013, but reported more than $7.3 million in bad debt; that year, the institution ran in the red.)

And while the preferred Medicare reimbursement afforded by its critical access hospital status helped the hospital partially absorb the blow, the providers out in the community had no such cushion.

“Like in other rural communities, manufacturing walked away and that put significant challenges on the health care environment,” said Bob Bednarek, vice president of rural health planning and development for Mission Health and president and CEO of Transylvania Regional till 2014.

So Transylvania Regional set about reinventing itself.

First, the hospital and physicians joined forces. According to Bednarek, Transylvania Regional was among the first hospitals in Western North Carolina to actively pursue employment relationships with area doctors. The hospital now employs 90 percent of the primary care providers in the county.

Then came the decision to become a member of the Mission Health system. Landis arrived at Transylvania in August of last year and has been guiding this transition.

A source of identity

UNC-Chapel Hill health economist Mark Holmes speaks of how small communities sometimes “think of their hospital as metropolitan areas think of their professional sports team”: an anchor of that community’s identity.

Cathy Landis, RN, was selected as one of 50 Critical Access Hospital CEOs to Know. Photo credit: Taylor Sisk

While that analogy often seems to no longer fit, it does appear to be the case in Transylvania County.

“We’re looked at as a real business partner,” Landis said, “vital to this community.”

When executives come to town to discuss the potential of locating their business in a community, “they ask about your schools and they ask about your health care,” Landis said. “And so we’re needed in the community for health care and we’re needed in the community as a business partner.”

In 2013, Transylvania Regional paid about $23 million in salaries and benefits. The hospital and its Mission affiliates are the biggest employers in the county.

The hospital has had to change with the times. Challenges faced by rural hospitals include addressing the fact that many of what were once inpatient services are now being performed on an outpatient basis. So a step in this redefinition process was discontinuing some services and enhancing others.

There are a number of summer camps in the area. Taking that into consideration, and factoring in a substantial senior population, hospital administrators focused on offering first-rate orthopedics and emergency services. Plenty of general surgery is still provided, but labor and delivery is not. Expectant mothers are now sent to Mission’s flagship hospital in Asheville.

“None of us wanted to give it up,” Landis said. “But at the same time, doing it wasn’t the right thing to do when you don’t do enough of it. So we talked with our community, our board was very supportive, and we said, ‘We need to do what we need to do to take care of our community, and do it well.’”

Mother and child can then receive post-partum care back at Transylvania Regional.

Now available in Transylvania County, Bednarek said, are “needed and appropriate specialists” alongside an “extraordinarily strong base of primary care.”

‘Hospital USA’

Landis recognizes her hospital’s responsibility to rise to the challenges of the burgeoning patient-centered medical home model of health care: keeping people healthy within the community and out of the hospital.

“Now you’re talking about Hospital USA,” she said.

The Transylvania Regional team. Photo credit: John Warner

“While we’ve always tried to do what we do well within our borders, now we’re asked to do, essentially, community health: keep a congestive heart-failure patient on his meds, keep him checking his weight,” Landis said “We’re in charge of the whole health care continuum. That’s going to be the challenge of every Hospital USA.”

And that tends to be a higher-profile role, Landis said, in very small communities: “It’s a heightened commitment, I think, just because you’re treating your neighbor.”

Concurrent with that, Transylvania Regional’s administration and board will continue to strive to keep care local: “Buy local,” Landis urges.

They’re building a new emergency department and medical office building. “We’re trying to do the right things in the right places,” she said. “About 70 percent of our care is already outpatient … so we’re poised well to keep up with the movement of health care.”

Landis anticipates working more closely with the public health department and better connecting with social and other community services.

Transylvania Regional is well positioned, Bednarek said, to ensure “that the patient is treated in the appropriate setting with the best outcomes and has a strong primary care home base of support. Transylvania has, over time, really tried to balance those things and be part of that strategic curve.”

“Which all leads to why Transylvania is a Top 20 hospital,” he said.

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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