Think about Americans living with difficult access to healthcare, much less the money to pay for it, and an urban area blighted by poverty may come to mind. While the problems of downtown medical centers struggling to adequately care for the poor in crowded emergency rooms and underfunded clinics are real, there’s another serious healthcare crisis underway in the U.S., far away from big cities.
Health systems in rural areas, where 20 percent of Americans live, are faltering. The ramifications, both for individuals and communities, can be deadly.
Over the last five years, at least 43 rural U.S. hospitals have ceased operation. That amounts to a loss of more than 1,500 beds, according to data from the North Carolina Rural Health Research Program. And the pace of closings is increasing, with over a dozen hospitals shutting down in 2014 alone. For people living in the countryside who need medical care, losing a hospital can literally leave them and their communities in critical condition.
Consider the small town of Folkston, Georgia, with a population of around 5,000 people. Have a life-threatening heart attack there and an ambulance will take you past nearby Charlton Memorial Hospital, now closed. You’ll be transported another 40 miles to an emergency room for care — if you make it.
In all, four of Georgia’s 65 rural hospitals have met the same fate as Charlton Memorial over the last couple of years, and others are on life support, still open but with slashed services.
Lack of money to keep rural hospitals running has several causes including a substantial drop in local funding and refusal of some governors, including Georgia’s Gov. Nathan Deal, to expand Medicaid to adults who don’t have dependent children.
The Affordable Care Act (ACA) created the Medicaid expansion, but it requires state funds. Gov. Deal, and 19 other governors who oppose the ACA, claim it is too costly for states. In all, Gov. Deal’s decision is expected to hit rural areas hard. It will keep Georgia from receiving about $31 billion in federal money for the state's healthcare system over the next 10 years, according to Tim Sweeney, health policy director at the Georgia Budget and Policy Institute.
Another cause of funding woes in rural communities is simple: Residents often can’t pay for medical services. They are more likely to be poorer, sicker, older, uninsured, and medically underserved than other Americans, according to the U.S. Department of Health and Human Services (HHS).
James R. "Randy" Lee, MD, agrees. The HHS description matches the rural population he serves in and around Hamilton, Texas.
“The majority of the people are elderly and, although they don’t consider themselves impoverished because of their background and expectations, they are economically disadvantaged,” he says. “They tend to be disenfranchised from many things available in the cities that are taken for granted, like reliable transportation. It’s often difficult for them to even get to the doctor.“
Not long ago, people in scattered communities of 1,000 to 1,500 people around the Hamilton area experienced a healthcare crisis that echoes what other rural areas are facing. How the situation was turned around is a tale that offers hope and strategies for other medically underserved communities.
Hamilton General Hospital, the area’s only medical center, opened as a 20-bed facility in l958. But by the early l980s, faced with growing financial woes, the hospital was sold. The new owners closed the money-losing facility in l987. Then a group of local citizens formed a non-profit group and worked to raise money to take over and reopen the hospital in l988.
But the hospital was struggling almost a decade later when Dr. Lee completed his medical training and returned to his hometown of Hamilton. His leadership in turning the Hamilton Healthcare System into a model for successful rural healthcare evolved, Dr. Lee says, “by default.”
“When I came back to the practice here in l997, there were only two doctors and one soon left after I arrived. The hospital had just 8 to 10 functional beds,” he explains. “Another doc, a friend from med school, and I opened Family Practice Associates in an old clinic and began a partnership with Hamilton Healthcare System.”
Dr. Lee and his colleague set out to change a system that referred patients onward to other facilities far away. Instead, they aimed for a community-based hospital that cared for a majority of patients’ problems locally. They modernized the nursing practice by re-educating nurses on protocols. And they began taking care of patients in any way they could.
“The care standards for Hamilton, Texas, are no different than for a big city like Atlanta so far as the expectations for quality and program compliance are concerned — but the resources to make those things come about are definitely different,” Dr. Lee says.
“So you wind up with physicians wearing multiple hats as department heads of chronic care programs in addition to being the primary care provider and working in the ER, seeing their patients in the hospital, nursing homes, and hospice. We work as a team and all of our nurses and docs have a tendency to have five or six jobs because there’s not another person with those skills and not enough money to pay for someone to do each job independently. It’s a big challenge.”
Payments for services by area patients are primarily from Medicare and Medicaid and are typically lower than private insurance payments and not negotiable. To succeed financially, the Hamilton Healthcare System, including the hospital, had to build volume. And they did.
Since Randy Lee returned to his hometown to practice medicine, Hamilton Healthcare System has grown and thrived. In 2005, a 34-bed, 39,000 square foot $7.5 million new hospital opened its door.
“I would say the secret to this is really pretty simple. People came because we cared about them and they knew we cared about them. I can’t emphasize that enough. I call it the Momma Rule. I always tell our doctors and nurses that it doesn’t matter what the problem is, take care of the patient just like you would your own mother. Treat them with respect and communicate well,” Dr. Lee explains.
Another key to successful growth of Hamilton Healthcare was focusing on outreach and carrying programs to where patients live. “People only had to go 10 or 15 miles instead of driving 100 miles plus to get continuity of care,” Dr. Lee says. There are now three rural clinics in surrounding communities, including one adjacent to the hospital in Hamilton, another in Hico, and a third in Goldthwaite.
Patients who can’t drive and have no one to take them to a doctor’s appointment use a federally- and state-funded transportation program called The Hop. A single bus serves several counties and, when scheduled far in advance, picks people up for medical appointments.
With rural physicians typically earning far less than their urban counterparts, convincing doctors to live and work in areas like Hamilton can be difficult. But Dr. Lee has added seven family physicians to Hamilton Healthcare by reaching out to those with a specific interest in serving underserved communities — and Hamilton, in particular.
Dr. Lee and colleagues work with a mentoring program, part of the Texas Family Preceptor Program, in the local school district to encourage youngsters with the aptitude and desire to go to medical school.
“We‘ve had multiple kids subsequently come back here after graduating from medical school and our initial mentoring role was a big factor,” Dr. Lee says. “Having local people go away and do well and then come back because they want to be vested in the community is almost like they have a 25-year head start on the patient/physician relationship. They already know the people and so it’s easy to engage the patient. That’s one of our strengths, no doubt. And our doctors are part of the community, volunteering to be on the school board, involved in kids’ sports programs, and as civic leaders.”
Dr. Lee received his medical degree from the University of Texas Southwestern in Dallas and did his residency in family medicine at John Peter Smith (JPS) Hospital in Fort Worth. JPS is nationally known for training doctors to work in underserved areas, including rural, urban, and international communities. For several years, Hamilton Healthcare and Dr. Lee brought JPS doctors in training to live and work in the community for a month to see firsthand the model of rural healthcare used in Hamilton. The program is set to resume soon and is another way that new doctors can be recruited for the area.
Despite being far from the big cities, Hamilton Healthcare System was early to adopt state-of-the-art information technology systems. Dr. Lee aggressively pursued compliance with Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, which provide financial rewards for using certified EHR technology to improve patient care through three stages. To receive an EHR incentive payment, providers must show that they are meaningfully using their EHRs by meeting thresholds for a number of objectives.
“We were the eighth hospital in the U.S. to achieve meaningful use stage 2 in the EHR incentive program,” Dr. Lee says. “The electronic medical records have been a huge challenge because it’s a whole other process that you have to learn. But it definitely helps us manage our patient population much better. For example, I can do a search for my diabetic patients who are not at their treatment goals and call them in for counseling with a diabetic educator, nurses, and dietitians and make rapid appointments. There is no way I could do that without our electronic tool kit.”
Dr. Lee worked for eight years to bring another innovation to Hamilton Hospital — a helicopter service to transport seriously ill and injured patients to specialty centers. “Before we secured a helicopter, patients with major trauma from a farm accident or wreck, or with serious burns, were sent on to the trauma hospital 80 miles away or a burn center about three hours away in traffic,” he explains.
Dr. Lee has also proactively pursued chronic care management programs. “My wife, Lee Ann Lee, is a nurse and she started the first certified cardiac rehab in the area with one treadmill in a room of our family health clinic. The rehab program has now received certification by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), which is the highest level of certification. She also started our pulmonary rehab program. We have a congestive heart failure and diabetes program, too. They are our core programs right now,” he says.
In order to find additional avenues of support for its services, Hamilton HealthCare, under Dr. Lee’s leadership, is participating in Delivery System Reform Incentive Payment (DSRIP) projects. Authorized through Medicaid, DSRIP provides incentive payments to hospitals and other providers to develop strategies that enhance access to healthcare and increase the quality of cost-effective patient care.
“Basically, you collaborate on projects that benefit the whole region and then you share the funds,” Dr. Lee explains. “DSRIP projects are designed to promote chronic care management as well as population health management. The goal is to keep people healthier so they don’t have to be admitted to the hospital. It’s a way to fund the transition between paying a premium encounter for an illness event and working instead on spending more time to try to keep people well. It’s another important venue to bring in more federal funds.”
So far, Hamilton Healthcare has collaborated with several partners in Texas and is now managing the DSRIP diabetes program for the whole region. “That is going to get us funding for developing protocols for use in hospitals and the communities they serve to try to make the health of diabetics better and help physicians prevent complications,” Dr. Lee says.
Where is Hamilton Healthcare System headed in the future? “Our focus is to be more active reaching out to the people in the area who have problems with transportation, who have educational barriers and limited resources. We want to use the power of our information technology to try to manage their health better,” Dr. Lee answers.
To that end, Hamilton Healthcare has launched a telemedicine program to improve access to specialist care. “Our telepsychiatry program has been very successful in closing access to care issues for adults and children with mental health issues,” he says.
“We are piloting a program with Baylor Scott & White Health (the largest not-for-profit health system in Texas) in hematology oncology, with a planned start this summer. And we plan to expand telemedicine to bolster our existing stroke treatment program through active collaboration with neurology. I foresee spin-off implementations in areas of trauma care, dermatology, and critical care oversight,” Dr. Lee adds. “I have been working with the Google Glass Explorer program to develop applications to facilitate documentation, communication, and consultation in real time. I see endless possibilities for empowering rural providers and improving the healthcare of rural America. "
“We are doing a good job now but want to be great. We are having community meetings with home health agencies, skilled nursing facilities, and others in healthcare so that we work together to help the people in the community as team. That’s the key, no doubt about it. We’re all in this together.”
August 06, 2015
Christopher Nystuen, MD, MBA