By Taylor Knopf

The mountains become steeper and houses fewer as you drive west out of Asheville on U.S. Route 25 and pass the sign that reads, “Welcome to Madison County: Jewel of the Blue Ridge.”

The county covers 449 square miles and has about 21,000 residents. There are three small towns: Marshall, Mars Hill and Hot Springs.

The whole region has that small-town feeling. There is only one high school in the county and school buses travel for hours transporting students. At noon, you can go to a popular eatery in Marshall called Zuma — across from the courthouse, next to the French Broad River, and run into old friends, including the health director or your dentist.

People who live in Madison have generations of family in the area. If you’re new to town, it takes a few years for locals to trust you to stay.

After 26 years, folks believe Marianna Daly is here to stay. For her part, she likes the “old-timey” small community. And she likes being “their doctor.” Daly is the Madison County Health Director and a primary care doctor at Hot Springs Health Program.

As a biology major at Princeton, Daly thought she would be a forest ranger someday. Later she discovered that she just wanted to “work with people somewhere beautiful.” Originally from Durham, Daly moved out to Asheville to pay off her East Carolina University medical school loans by working in a rural area. But she stuck around.

Photo shows all the staff standing on the steps of the main facility.
Hot Springs Health Program in Madison County has grown from a two nurse operation to 128-member staff over 45 years. Photo courtesy of Hot Springs Health Program.

Hot Springs Health is unique in many ways, including its ability to keep large numbers of Madison County residents out of the Asheville emergency rooms for non-life threatening conditions. Daly attributes much of it to the clinic’s extended evening and weekend hours.

With four locations throughout the county, Hot Springs Health Program is the sole medical provider for the county outside of the county health department. Two of the clinics are open until 7 p.m. on weekdays and see patients on weekends. Outside of regular business hours, HSHP providers see around 14 patients in the evenings and about 46 on the weekends.

Madison County’s rate of potentially preventable readmissions to the emergency department is 54 percent lower than expected, according to Community Care of Western North Carolina.

One stop shop

Hot Springs Health Program is a primary care center, but in addition to regularly scheduled patient visits, the physicians end up taking care of many urgent needs.

“For them to come to us rather than go to [Asheville Mission] hospital is a big piece of it,” said Teresa Strom, director of Hot Springs Health Program.

Data, graph courtesy Community Care of North Carolina showing that Madison County’s emergency department visit rate (dark blue line) is lower than expected (light blue line).

“A lot of counties have patients that go straight to the emergency room for their strep throat and all those things,” Strom added. “So that generates all these claims. For us, we must have less claims of people that go there.”

When a patient goes to the emergency department, their card lists a “medical home.” If their medical home is HSHP, that will show up in the data.

Daly added that she sees patients with fractures, chest pain, pneumonia and those who need stitches. She added that many primary care doctors don’t see these tasks as part of their job if there is a hospital in the vicinity.

“But in our county, [people] don’t want to go to the emergency room and they know they have two offices open at night and the weekend where they can go get stitches,” Daly said.


If a patient has a fracture, Daly said she stabilizes it with a splint. The patient schedules an appointment with an orthopedist, bypassing the emergency department altogether.

Daly suspected that a recent patient might have appendicitis. Instead of sending the man to the emergency department, she took some samples and had someone drive them to the lab at the Hot Springs Health Program’s Mars Hill office. His levels were normal and she kept him out of the emergency room that night.

LabCorp, a medical testing company, rents space from HSHP, so the doctors have access to a STAT (immediate access) lab, which is rare for a primary care office. They also have an X-ray and can do IV hydration in the office, another rarity for primary care providers.

photo of main building
Hot Springs Health Program has four locations spread across Madison County, and two serve patients after hours and on weekends. This is the Marshall office. Courtesy of Hot Springs Health Program.

“We don’t want to be urgent care, but we have morphed into everything,” Strom said. “Not that we advertise that. It just happened. We don’t deny our patients that urgent need when they come in because a lot of them don’t want to go to Asheville and we can do it here.”

Hot Springs Health Program provides pediatric and family care to hospice services. Physical therapists through the program provide home care. Additionally, every HSHP doctor is also a state certified medical examiner.

Daly said that if someone dies in the county by homicide, suicide, under suspicious circumstances or accidentally, a HSHP doctor is called to investigate. They do everything but the autopsy. More urban counties have coroners or people designated to do this job. But in rural counties like Madison, this is the way it’s done.

From small beginnings

In 1971, two nurses moved to Madison County and opened a small clinic in Hot Springs with the big idea of providing the mountain residents with local health care.

As more people joined the mission, Hot Springs Health Program evolved, operating on patient fees, volunteer labor and a little grant money.

photo shows woman holding a stack of files, standing in a snowy yard in front of a house with a large woodstack in front of it
Hot Springs Health Program hospice nurse Chris Plemmons makes a home health visit. Courtesy of HSHP.

Driving through the mountains, Daly pointed to a tiny box-like building next to a cemetery that now houses a 24-hour diner. It use to be a HSHP clinic.

Daly and Strom reminisced about their days working in that little space.

“The X-ray table was the lunch table,” Strom said.

Daly recalled moving outside for lunch so that the veterinarian from down the street could use the X-ray for a dog.

“We have come a-ways, have we not?” Strom said to Daly laughing.

Today, Hot Springs Health Program has four, fully functioning facilities and a $6.5 million payroll with 128 employees, including 19 primary care providers. In 2016, HSHP pharmacies filled 100,000 prescriptions, and providers conducted about 50,000 patient visits including those in the jail, nursing homes and in hospice care.

HSHP is community-owned and does not receive county, state or federal money. Strom said the program survives on its own cash flow.

The providers are committed to the community and patients trust them.

Seven HSHP primary care providers worked there longer than 20 years, Strom said. And providers see generations of patients.

“It’s nice to have people really trust you,” Daly said, “but it’s also really scary to have someone say to you, ‘I won’t come in if you’re not here.’”

While there are disadvantages to a rural setting, such as access to fewer resources and specialists, there’s a unique community bond.

For example, a major blizzard hit the area in 1993, which some news reports called “the storm of the century.” The roads were impassable and the residents of Madison County were trapped in their homes. Daly remembers first responders getting on horseback to deliver food, oxygen and medication to residents.

“There is a commitment to taking care of each other, family or not,” she said.

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

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