Q&A: The Critical Condition of Rural Health Part 2

The first part of our discussion with Tim Putnam,  President of the National Rural Health Association (NRHA), leading up to the Critical Access Hospital Conference, focuses on the state of rural healthcare and the need for a rural specific payment model.

Part two continues the dialog with a look into Putnam’s unique solutions for growing his community’s rural healthcare workforce, as well as tips for fighting the opioid epidemic. The conversation wraps up with his thoughts on what legislators can do to help sustain rural healthcare and empower rural providers.

MEDHOST: Tell us about your unique approach to solving for healthcare workforce shortages in rural areas.  Can you explain your agrarian concept and how it can help the rural hospitals acquire and retain healthcare professionals?

Tim: Traditionally, the approach has been “we have a shortage of nurses and doctors, let's become hunter-gatherers and put ads out, and try to recruit people to be part of our community.”

It's a challenge to get people to move to a rural community. What we've had more success with, is this agrarian philosophy—growing our own healthcare professionals. Students interested in healthcare—who can give up a class during the week—are welcome to come and do a mentorship or shadowing program at our hospital. They can be in areas like the ER, surgery, obstetrics unit, and our wound clinic.

We find that many participants come out with an interest in healthcare as a career. Upon completion 80 percent of the students say they want to be in healthcare.

Afterwards, we continue to nurture and help those who are interested—What's a good nursing program to go into? What's a good physical therapy program? During the summers, can we help you come back?

This has created local students who will go to college, come back, practice and live in the area they grew up in. It is a valuable program, but it takes a long time to see the results. But the time you invest in planting the seeds is worthwhile. Even if you understand it is a three, four, five, or six-year window, it still gives a hospital something to look forward to.

MEDHOST: There is a wealth of data that shows rural communities are disproportionately affected by the opioid crisis. Where do we start trying to contain its spread?

Tim: We need to actively control attempts to reduce the number of opioid prescriptions that people receive, whether it's limiting pain medications in the emergency department or looking for alternative therapies.

For example, the anesthesia department at our facility works closely with our orthopedic surgery program on techniques prior to surgery that can reduce the amount of pain immediately afterwards. In this way, our surgeons aren't prescribing nearly as many opioids post major orthopedic surgery. A patient coming in with a kidney stone may see an IV of lidocaine as opposed to morphine to treat the pain of passing the stone. We need to get creative with things like that, realize the damage that can be done by long-term opioid prescriptions, and use extreme caution. That's the first thing.

The other is realizing the challenge we've got ahead of us and making treatment options available. The treatments that work in urban areas don't typically work in rural areas. You can put someone through a treatment program in a rural area, but they're still living in the same place with the same challenges. How do you create a treatment program that's outpatient focused and helps a person through, without removing them from the environment that caused the addiction in the first place?

MEDHOST: You mention better visibility into patient health data—knowing what medications patients are on is part of preventing opioid abuse. How can rural facilities improve in this area?

Tim: From an IT perspective, rural hospitals need an accurate flow of information from physicians’ offices to tertiary facilities to 911 EMS. This is tough because many rural providers don’t have an all-encompassing electronic health record. Twenty or 30 years ago, all that patient data was kept away in a file folder. It’s still that way in some places.

Access to patient health data in real-time will give rural hospitals the best ability to provide great care. No matter where you are, to properly treat a patient you need to know patient history. You also need to know what other things are going on with that patient apart from recent treatments.

From an IT perspective, I see that as absolutely vital. I see a lot of my colleagues in urban areas not wanting to openly share their data. At the rural hospitals, we want to share it. We want to get data from everybody else because we want to know everything we can about that patient to the best of our ability. From an IT perspective, that's an imperative going into the future.

MEDHOST: What kind of regulatory challenges are rural hospitals facing and what do you hope to see from legislators to help reverse the current course of closures?

Tim: We need to have something to look forward to. We're seeing too many rural hospitals close. One closes every three or four weeks in this country. So many of my colleagues are running on fumes to keep their organizations open. What can legislation do—from changing the payment model, to shifting how hospitals are reimbursed by Medicare and Medicaid—to be able to stay viable?

Once hospitals close or even start to close services in rural areas it makes the community no longer economically viable—they will become the ghost towns of this generation. We've come to a point where we need to try and stop that from happening, but it's going to take an investment from the legislature to realize that rural healthcare is valuable.

Even if you don't care about rural communities, you have to realize that people in cities occasionally visit rural communities. If you've got an area where there's no EMS response or a hospital, a 911 call becomes obsolete.

Without simple access to healthcare, rural communities are put in a very difficult economic situation. The message can’t be clearer—there needs to be action on the legislative side to focus on the propositions we’ve posed aimed at making rural healthcare viable.

MEDHOST: What do you think both lawmakers and healthcare leaders need to know about reinforcing rural healthcare? Where are they missing the mark when it comes to protecting these at-risk communities?

Tim: One aspect is how we define a hospital. The best model we have right now is a critical access hospital model: a 25-bed hospital that is inpatient focused. It is an industry model based on patient experiences from the '70s and '80s.

Today we are looking at much more aggressive outpatient treatments. It's more about getting the community to have 24-hour access to emergency care, but also having someone monitor the health of that community and their health needs. That's more important than having inpatient beds.

One model is based on creating outpatient focused hospitals. In this instance we don't necessarily need all the inpatient capabilities, but we've got 24-hour access. What results is a lower cost to operate and services that rural communities really need to survive. This will also reduce the cost of care and can build sustainability into rural communities.

We're stuck on hospitals being inpatient services only. Currently, there's no feasible payment models for rural outpatient hospitals.

To learn more about NRHA’s efforts to support rural healthcare and the upcoming Critical Access Hospital event, visit http://www.ruralhealthweb.org/events.

If you are already registered, make sure to stop by our podcast lounge at NRHA Critical Access Conference and join the conversation. Click here to reserve your spot on our guest list.