Season 2 Episode 12
Hannah Shultz: Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country highlighting that we all share in public health. Thank you for tuning in to this series which focuses on rural health in the Midwest. Over 10 episodes, we talk with people in a variety of communities about their experiences and perspectives on rural life, employment, and health. Our aim is to deepen understanding of the complexity of rural life and celebrate rural areas. We’re so happy you’re listening and learning along with us.
Hannah Shultz: Welcome back to the Rural Health Series of Share Public Health. Today, we’re going to talk about healthcare delivery in rural areas. We’ll talk with a healthcare provider, a nonprofit leader, and a hospital administrator in the next hour. I learned a lot in these conversations and I’m glad you’re joining us.
Hannah Shultz: Our first guest today is Dr. Jessica Williams. Dr. Williams is a dentist at River Hills Community Health Center in the Southeast Iowa town of Ottumwa. She tells us a bit about her background.
Jessica Williams: I’m originally from north of Chicago. I went to college at Howard University in Washington, D.C. and then back to Chicago for a dental school, and then I applied for the National Health Service Corps Program and I ended up in Ottumwa, Iowa, but that was by my choice. So, some programs are a little bit more flexible than others, but when I was looking at places to apply to, Ottumwa really stuck out to me, and I applied, and so here I am.
Hannah Shultz: Not to state the obvious, but Chicago and Washington, D.C. are big places, the third and sixth largest metro areas in the United States, respectively. I asked what the move was like and what surprised her most when she came to Ottumwa.
Jessica Williams:I’ll say that it surprised me how people are … The quality definitely surprised me because everything is pretty low cost or like I said, doesn’t have a lot of bells and whistles, seem really modern, but the quality of a product is still there, the quality of the service is still there. So, that’s why I really do tell people, I’m like, “It’s really great. It’s a win-win because it’s low cost of living, but also very high quality of life.” So, that’s one of the things that pleasantly surprised me about moving to a rural town such as Ottumwa. That is something that I really do try to highlight to people is that, “Yeah. Some of these places have bells and whistles, and whatnot, but I would say that, like I said, the quality of the product and the service definitely meets that standard on urban or a metro area. Coming again from Chicago to Ottumwa, I’m like, “Oh, my God! This is such a small town,” but then once I got there and I learned that people were from even smaller towns, and this is a big city and then I was like, “Oh, my gosh! It’s really all relative.” I tell some people, actually, I always like hearing about some people’s population of this town that they’re from. Fewer people then who went to my high school and I’m like, “My graduating class was more than the community town.”
Hannah Shultz: I love this part of Jessica’s story. She’s been at home in a major city and in rural Southeast Iowa, but that doesn’t explain why she’s in Ottumwa. Jessica says she practices public health dentistry. Listen how she explained what attracted her to public health and to move in to rural America.
Jessica Williams: When I was in college, I knew that I wanted to work in a community health center. So, that was always on my mind. When I was coming to the end of dental school, loans. I’m just going to be honest. Loans was a huge factor for me. So, I heard about the National Service Corps Scholarship, where you could work in a community health center, but also receive assistance for paying off your loans. For me, that was a win-win. I was like, “Oh, this is perfect because I knew I want to work in a community health center. That’s something that really interests me, but also I would have assistance paying off my loans.” So, because, again, I knew I wanted to do the National Service Corps and I wanted to work at a community health center, I said, “Why not do a national search?” Even though I’m here in Chicago, I could find a clinic in Chicago. I was like, “Why not? This is one of a chance of lifetime where I could go anywhere in the country.” So, I just did a national search, and I just looked at different clinics and looked at their missions and looked at the opportunities that they had, and River Hills was a great clinic. I talked to them. So, I already in my mind had the mindset that I was going to be in a very rural area or something like that just because, again, I was thinking of doing the National Health Service Corps. Typically, that’s what deters people from it is, “Oh, you end up in the middle of nowhere.” So, I had always in my mind thought, “Yeah. I’m from Chicago. I’m used to urban settings, but I’ll probably be in a rural community.” So, that’s why, again, it wasn’t like, “Oh, no. I can’t work there.” So, that’s why I was very open to that possibility of Ottumwa, Iowa. So, like I said, I did a national search, came upon River Hills. The people were just super warm, super friendly, and that’s really what drew me to that clinic and why I accepted the offer is just because the people were great. They were wonderful people. Public health is really difficult, public health service, public health dentistry. If you’re not working with people who really share your value, share your mission, and you want to be able to get along with your colleagues when you’re doing very difficult work. So, for me, it was really the people who made me think, “Oh, okay. So, this will be a really nice place to work.”
Hannah Shultz: Jessica just said public health is a difficult field. I think we recognize this now in the midst of the COVID-19 pandemic, but I don’t think we said this enough before the pandemic. I’m not sure people entering public health as a profession know this.
Jessica Williams: You’re dealing with very complex situations. So, I’m not just dealing with a tooth that needs a filling. I’m dealing with a tooth that needs a filling from somebody who has diabetes, anxiety, COPD, asthma, they’re coming off of a meth addiction, they’re borderline homeless, they have trouble getting transportation to the clinic, they’re going to need a lot of specialty care. So, things can get really, really complicated and really complex when we’re serving populations that are vulnerable, that are very high risk. So, that’s really what makes it difficult is having to deal with so many different parts of healthcare delivery. It really does show how the social determinants of health all play into health delivery, but also health outcomes. So, like I said, transportation, social history, dental history, medical history, all of that plays into just, again, doing that filling. So, that’s what can make public health delivery a little bit different than a private practice.
Hannah Shultz: I asked Dr. Williams how dental school prepared her for public health dentistry.
Jessica Williams: Dental schools are largely a safety net for people who are low income, vulnerable populations because a lot of dental schools offer reduced fees and lower costs. So, again, a lot of people end up going to the dental school for the care that they need if they can’t afford it elsewhere. So, you really do get a taste of the needs of your community around your dental school. Like you said, we did do rotations as well in the community at community clinics, and that also gives you another taste of the needs in the community. So, you really get a good foundation of public health dentistry when you’re going through your dental school training.
Hannah Shultz: Jessica explains what is different about practicing in a rural area compared to an urban area.
Jessica Williams: The needs are similar. The people, the demographics are different. The access to care is also a little bit different because if you’re walking down a street in Chicago or Washington, D.C., New York, you’ll see a dentist on every block or maybe multiple dentists on a block, but how many people can go into that office for care? How many people can afford it? How many people have the insurance that’s accepted?
Jessica Williams: So, access to care in an urban setting, what I found, the barrier was largely finances. Whereas in a rural community, the barrier, it can also be finances and insurance, but there are fewer providers. So, like I said, maybe there’s not a dentist on every block necessarily, but one or two dentists spread out here and there, but if they don’t take your insurance, then, of course, still you’re not in luck. The issue is, like I said, there are really not that many providers. So, you end up having to travel a very far distance to get the care that you need. So, then the biggest barrier to access to care is transportation because your providers are just so far away, or the providers that you need at the time are so far away. So, that’s what I found was the largest difference between urban and rural was really transportation to a dental clinic.
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Hannah Shultz: She has a lot of good things to say about working in a rural community.
Jessica Williams: Some of the positive aspects of practicing in a rural community I would say are being able to really connect with your patients and really build a relationship with them. Like I said, with public health, public health can be challenging, but it can also be rewarding because you do know all of the different factors that this patient is coming to you with. So, you really are able to build this connection and this relationship, this patient-provider relationship with them. So, we can talk about, “Oh, I see that you stopped smoking.” “Yeah, I stopped smoking. It’s been about two weeks now.” It’s like, “Oh, great! What’s helped you do that?” “Oh, my grandmother. We had this going on, and so I wasn’t able to smoke.” So, you’re just getting to really know your patients. I find that that’s really rewarding because being a safety net clinic, you do end up seeing a lot of patients and their families and it really does become a dental home. So, like I said, building that relationship with your patients I think is really possible because we are in a rural community and because we are the only safety net in the area. So, we really do get to see our patients and build a connection with them and their families.
Hannah Shultz: River Hills, where Jessica practices, is unique and that it offers integrated comprehensive care.
Jessica Williams: The integration of the different professional fields is one of the reasons why I selected River Hills is because it had all of the different services in that one clinic. For me, medical-dental integration is really important. I really do see that connection, and I really try to promote to other people that connection of oral health to the overall health. I knew that as a provider I needed to be able to speak with other health professionals about my patient because I don’t just want to treat a tooth, I want to treat the individual. So, that was really important to me when selecting a place to practice is to be able to talk with the primary care physician, to talk with the behavioral health, to talk with the pediatrician about the patient’s care, about the patient’s overall health. So, yes, River Hills offers more than just dentistry, like I said, medical, behavioral, women’s. It offers comprehensive care and really what we see is that comprehensive care is the best care for a patient. So, medical-dental integration feels really important to me when selecting a clinic.
Hannah Shultz: It’s funny that we talk about oral health and dentistry as being separate from general healthcare.
Jessica Williams: Oral health is connected to overall health. The mouth is the portal to the rest of the body. We can’t separate the two. For too long, it’s been separated, seen as a separate entity when it really does impact the rest of the body. So, when we talk about overall health, when we talk about population health, just like you’re only as strong as your weakest link, you’re only as healthy as your least healthiest person. A lot people, what you’ll find is that they’re missing teeth or that they have had how many emergency, how many time had they been to the emergency room in the past year for a dental problem. So, those are all things that you can really evaluate in a community to get an idea of the health of that community.
Hannah Shultz: Earlier in our conversation, Jessica mentioned that access to care is different in rural areas. She tells us more about where people can go for specialized dental care.
Jessica Williams:It depends on the insurance, honestly. So, a lot of patients, I guess, we end up referring to the University of Iowa because that’s really the safety net for our Medicaid populations and people who are really low income, can’t pay much out of pocket. So, University of Iowa is usually our safety net for people who have really specialized needs. Luckily, Iowa is great because they did recognize that transportation maybe an issue. So, there are options for people to get transportation if they do have Medicaid. So, that’s a great thing, but for the most part, transportation is largely, “Oh, how do I get up there?” or “I can’t take off work,” because it’s also time. So, maybe you do have transportation but you just don’t have the time to carve out to travel about an hour and a half, two hours up there only to have a procedure take about four hours and then have to drive back. I mean, that’s a huge, huge chunk of time out of somebody’s day.
Hannah Shultz: Dr. Williams talks about the importance of programs that exist to help un or underinsured Iowans.
Jessica Williams: So, this is where when we’re talking about Iowas specifically, programs like iSmile and iSilver are super important. Programs like these connect community resources, departments, agencies, and healthcare centers, medical providers, dental provides all together to get kids and older adults the care that they need, and has been huge in our community or it makes a hugely positive impact on our community to be able to connect people through those community resources so they can get the care, so the children can get the care that they need. We also found out with COVID, of course, and I don’t think this is just our rural communities, but all communities have found how important it is to have a connection with your public health department. So, connecting with your public health department and sharing data and sharing resources and maybe even sharing workforces and collaborating with each other and just keeping each other up-to-date on everything we’re finding is super, super important.
Hannah Shultz: Recognizing the importance of collaborating with public health, Jessica explains what that means.
Jessica Williams: Like I said, what we find in public health dentistry in primary care is that the social determinants of health really do impact people from getting the care that they need. The health department is the community resource that can bring in different professionals to help, again, people getting the care that they need. So, we really need to be a part of that, dentists do, because like I said, if we’re going to do medical-dental integration, then we really do need to start becoming more, if not already, more involved with the public health department. The public health department oversees all health and all things and dentistry is health as well. So, it needs to be included in that.
Hannah Shultz: Telehealth is a big topic these days. I was curious if telehealth and dentistry could ever go together.
Jessica Williams: There is a huge, huge opportunity to connect people to care. A lot of times, we’re find that you don’t need to actually come to a clinic. You just need to talk to a professional and maybe see the professional, but maybe they don’t need to physically be in the clinic and just think about how many people we can benefit by just allowing them access to those services, those platforms. Especially our primary care, behavioral health, it’s a great, great opportunity to connect, again, people to care, but with dentistry, it’s a little difficult because it’s like, “Okay. Well, how are you going to do this,” and we need to touch the patient. Well, no. We are finding out. Maybe we don’t need to touch them as much as we thought. Maybe we don’t need to actually have them in the chair as much as we thought. So, even in dentistry, we’re finding that telehealth can be of good use.
Hannah Shultz: Jessica is a great advocate for public health and for her patients. She shared why this is a specially important for rural patients.
Jessica Williams: I would say when it comes to rural health, we really do have to have more opportunities like this, where we can advocate for our rural patients and our rural communities because voices could largely get drowned out and even though we have similar needs, we also have some things that are more unique to rural communities, barriers to care. So, barriers to care for rural communities include transportation, huge barrier, not a lot of providers in the area, recruitment and retention. So, there are some things that we really should be trying to focus on when it comes to how do we strengthen our rural communities, how do we strengthen the healthcare that’s provided to rural communities. So, broadband, internet access, huge. Provider recruitment and retention, how do we get providers like myself who’s been through the National Service Corps, and through the loan payment, what can we do to attract more healthcare workers to the area so maybe transportation doesn’t become a problem, so we have the wonderful problem of, “Oh, which person should I choose to go to because I have the insurance that could be used at any provider.” So, there are things that are very unique to rural communities that we really need to be at the forefront and be discussing in conversations when it comes to increasing access to care.
Hannah Shultz: Dr. Williams’ last comment here are a great transition to our next guest and her experience in rural healthcare delivery. Rachel Goss is the Executive Director of the Family Planning Council of Iowa, which is sometimes shortened to FPCI and she may say that throughout our conversation. Rachel lives in Eddyville, Iowa, which is near Ottumwa, where Dr. Williams lives.
Hannah Shultz: Rachel is a mom and an army veteran, and she has worked in rural healthcare for a number of years. Currently, she works in Des Moines, so she is a super commuter, at least 90 minutes each way in good weather and without traffic. Before diving into her role in healthcare delivery, she tells us a bit about why she loves living in a small town.
Rachel Goss: The people really care about each other as neighbors and friends, even I just think about our local gas station and I’d say our local gas station, singular or Melody’s restaurant downtown. When you walk in, you really are treated like family. So, I think anytime we hear of somebody in the community that’s struggling or a family that has a need, people step up and respond in a way that’s nonthreatening, and it just feels very wholesome, for lack of a better word. So, not that there aren’t perks to living or thriving in an urban area. I definitely love the city. I love coming to Des Moines. I love Downtown Des Moines. You cannot beat the friendliness of a rural Iowan, and you won’t convince me otherwise. I’ve only lived in Eddyville about six months, but I was living in Ottumwa for the last five years. So, I have commuted from a smaller community to Des Moines for work for at least three, four years, but that’s how much I love that small town feel and just– I’ve considered moving to the city many times, but I’m a single mom raising two latchkey kids because I do go to work and have a job and while the commute keeps me on the road, I feel really safe. I know every single student, I know every single parent. There are just some real benefits. I actually lived in this community back 10 or 12 years ago when my children were born and came back just because I loved it so much.
Hannah Shultz: Now, Rachel tells us about her career and how she ended up at the Family Planning Council of Iowa.
Rachel Goss: I started in healthcare as an X-ray tech, so working on the front lines of service delivery and have just slowly worked my way up, if you will, into healthcare administration. My role previous to this position, I was the Surgical Services Director for Planned Parenthood, and then prior to that, I spent the rest of my years in critical access hospitals in Southeast Iowa, primarily. So, I’ve worked also at the University of Iowa for a short period of time as front line X-ray tech. That was many years ago. So, I do really feel like I have a good idea of what separates really urban or large health systems from the care that’s delivered in the smaller communities.
Hannah Shultz: While, FPCI is in Des Moines. The organization supports providers across the state. I was curious what is different about care in rural areas.
Rachel Goss: I think one of the biggest challenges that we’re seeing right now is access. So, I think that is across the board, but particularly challenging for family planning as there’s just a lack of rural healthcare providers in general. So, it can be hard to get an appointment. This is why I would say expansion of broadband access to rural areas and telehealth is so important because I do see a real opportunity with a lot of the services that we provide in family planning, not necessarily being so hands-on, if you will. It’s a lot of times a dialogue between a provider and a patient or a nurse and a patient and decision making versus actual clinical care. So, I think there’s a lot of opportunity. Access is primarily an issue, and then taking it a step further, if you’re in a rural area, there might not be as many pharmacies. The pharmacy that you go to might not carry the birth control method, for instance, that you desire to have. So, really, it can be supply management issue, and then one of the biggest things I see, too, is confidentiality. All healthcare is personal. All healthcare is bound by federal privacy laws. However, that doesn’t mean it’s easier to have a conversation with somebody that you might see outside of your community at a social setting, for instance, about what birth control method might be right for you or a sexually transmitted infection or some strange symptoms. So, that often, I think, those three things I would say would be the biggest challenges to reproductive healthcare delivery in rural areas.
Hannah Shultz: We know there are shortages of all source of professionals and specialists in rural areas, but how does this impact reproductive healthcare?
Rachel Goss: It could be probably at least an hour in some case or generally an hour in many cases. There are just specific demographics areas of the state at FPCI. We call them service delivery areas, where there is just a real lack of providers and access, and even willingness in some cases to provide basic reproductive healthcare, sexual health services such as even something as simple as birth control. So, we at FPCI actively trying to engage with providers in these what we like to call Contraception Deserts. However, we were making ground pre-pandemic and then now here we are in the middle of a public health crisis. CEOs are not knocking down our door to work with us and rightfully in some ways so. Although, many would argue that access to birth control and those services is more important now than ever.
Hannah Shultz: So, a few minutes ago, we heard from Dr. Williams about what she thinks are the benefits of providing care in rural areas. I asked Rachel the same question. Notice she answers the question in a pretty similar way.
Rachel Goss: You get to know your patients on such a more personal level than you could ever imagine in that large delivery system, so much so that they trust you to the point where they even consider you family, if you will. They’re sending you handwritten Christmas cards. They’re stopping by your office with cookies, and brownies, and sometimes even small gifts to their healthcare provider because they really see them as an extension of their family. With that, as a provider, becomes some privilege of additional health history. You see them in the community. You might go to sporting events. Again, this is much pre-pandemic, but you get an intimate knowledge of your patient and they have you in that trust just really increases the opportunity to provide really personal quality care.
Hannah Shultz: If one of the benefits of being a rural healthcare provider is how you get to know your patients, one of the challenges that comes with the shortage of specialists is also a shortage of relationships the specialists can have with their patients.
Rachel Goss: I think family planning services, again, take a backseat to primary healthcare as priority. So, when I think about two specialty providers and rural hospitals managing a lot of those extra physicians in many of our communities, you’re not going to have a podiatrist in town. You might have a primary care specialist, but they might have an independent clinic or be working as part of a small hospital, but then if you need a gastroenterologist, if you need a reproductive healthcare specialist, oftentimes, patients in rural areas are faced with two choices. You drive to a more urban area at additional cost and time and time off work, and we have to think about all those things or you wait a month or more for that traveling specialist to come through your hospital where they, I can tell you from personal experience at multiple hospitals, the schedules are packed. The nurses often come with them. Rural patients aren’t as comfortable seeing those doctors that come from the big city, and they don’t have that level of trust established. So, as a clinical worker, you can just hear their health history or their story just is not taken into as much consideration, I think, as it could be if they were able to get care through someone they knew and trusted. Also, with those traveling physician schedule, something I noticed unique to rural areas, a lot of the people that live in rural areas are a part of the farming community or a manufacturing community, and when I think about those farmers that need that type of care, if the weather is good or if it’s a certain time of the year, they will miss those appointments if they can’t flexed to a rainy day. That is just the fact. So, literally, we would have at certain doctors’ offices I’ve worked with in the past a short call list of farmers, “Let’s get them in. It’s raining today.” We know they’re not going to be out in the field. So, that’s the positives about it. You really know those folks. It’s just a layer of intricacy that is like nothing else I’ve ever seen.
Hannah Shultz: Rachel is about to tell us a little bit about the Family Planning Council of Iowa. They have a fairly unique setup.
Rachel Goss: So, the nice thing and what’s unique about the Family Planning Council or FPCI is we subcontract all of our health services. So, while we receive federal grant funds through the Title X program to give the very best care in sexual and reproductive health, we’re actually doing that by contracting, for instance, with local public health departments or small or federally qualified health centers or critical access-sized hospitals. So, we’re able to keep the care in the communities that are willing to have us there, and that funding goes right back to the local level. So, that’s why I love the job that I have and what I think that we have an opportunity to do because while we’re keeping it local, we also have a our finger on the pulse of what is the most up-to-date information regarding contraceptive access and care, how can we give this information to the providers and make it really easy for them to deliver the type of care in the setting our patients are comfortable with. So, that’s why the position is unique and why I really like the job that I have now because it’s an opportunity to increase the quality of care at the local level while maintaining also a level of consistency. We’re definitely not alone in how we deliver services. However, I think that there are some states that delivery this type of grant or service through primarily one entity or agency. One of the things I learned this past year is it sometimes can be really good to have a little bit of a variety in the service delivery because when we have to respond to an issue or a crisis such as a global pandemic, you’re going to find out really quickly what works and what doesn’t, and if the communication is good between all of these agencies and FPCI tries really hard to be that hub to bring all of our agencies back together regarding family planning and reproductive health, what can we be sharing with everyone in a streamlined, succinct way? How can we support these agencies? I have to say I think when people hear the word family planning, everyone’s heads automatically go to, “Oh, planned parenthood is the best and the only place to get care.” Let me say, and I stated it previously, I’ve been an employee of planned parenthood. FPCI wants to be good partners with planned parenthood. We have mutually exclusive goals. However, they’re not the only player in the game. We work really hard through the federal Title X program to make sure that rural Iowans have access to care, and our network doesn’t include any planned parenthood at this time. So, I think it’s important for people to also understand that the program that we are referring to through the Feral Title X program is based on your ability to pay. So, there’s a possibility, based on your family size and income, that you might not have to pay anything for your birth control or STI testing or your sexual reproductive health needs. I would also say there’s two things. So, that would be one thing, I think, that’s important for people to know is there are other very qualified people in your community that can help you figure out your birth control or reproductive healthcare needs. The other piece, I think, that is important to call out or I wish people knew were that there are federal confidentiality laws within our Title X program. So, if you’re coming to a FPCI-sponsored family planning clinic, even teens can get confidential sexual and reproductive healthcare such as a birth control prescription without having to go through their parents or use their parents’ insurance or have their parents’ income used as a basis for determination on whether or not they can pay. So, while we encourage adolescents and teens to talk with their parents about birth control, we also recognize that there are times when that just isn’t an option for teens and youth, and we don’t want that to be a barrier to care.
Hannah Shultz: Our final guest today is Jim Atty. Jim is the CEO of the hospital in Waverly, Iowa. He’s worked in a couple other critical access hospitals in Iowa, and has been in Waverly for nearly seven years. He told me why he moved to Waverly a few years ago, and a bit about what the town is like.
Jim Atty: Waverly is specifically, again, I’m from this side of the state, and so it has been nice being this close, but, really, it’s been more about the work. So, trying to find something that’s been a good fit for and my family, and Waverly was interestingly enough a place that I interned at or, excuse me, I interned for a consulting company while I was in grad school. We had a project with Waverly, and we came up here, and my boss at the time had nothing but good things to say about Waverly and about the hospital. So, it was always one of those facilities in the back of my mind. When the opportunity arose, and we really started looking into it, it really shined. It’s a great facility. It’s a strong facility, but more importantly, it’s a good community, one where I feel safe with my kids riding their bikes wherever they want to ride their bikes, sometimes maybe a little too far, but they’re out and about, have opportunities to learn and grow. There are resources for us here. There’s great schools, great churches, and just a great community. So, why I came here was on a whim, right? It was my boss’ recommendation, but the reason that we stayed here is because it really does everything have we want and need.
So, Waverly is a rebirth in Iowa. It’s one of the few rural-growing counties, and we also have in average age underneath the state average. So, again, a couple of unique things from rural Iowa. We’re located just north of Black Hawk County. Bremer, Iowa has about … I’m sorry. Waverly, Iowa has about 10,000 people, which is the majority of the population in our county. We’re right next to Butler. Chickasaw and Floyd County, which we consider parts of those counties are our primary market as well. So, right when you get north of Waterloo Cedar Falls, the state starts to get a little bit more rural, and once you get north of Waverly, it starts to get even more rural. We try to service an area of about 55,000 people in that multi-county area.
Hannah Shultz: I don’t know much about critical access hospitals, so that’s where we’re going to start this conversation.
Jim Atty: So, we’re a critical access hospital, with 25 beds, four of which are labor and delivery. We’re about 120+ million gross revenue, 500 employees, and our employed medical staff is in the 40s. So, if we break that down a little bit more, majority of them are primary care. We do have a five-member team of OB-GYNs that includes a nurse practitioner and a midwife. We have two general surgeons, one of which does, he’s in our general surgery department, but does advanced laparoscopic and does bariatric surgery. Then we partner with Cedar Valley medical specialists primarily to provide some specialist care. We employ our own emergency room docs. So, we have a five-team rotation there and three licensed practitioners that serve in some capacity to try help out during the busier times, three hospitalists that take rotations and cover all hospital work. I think the most unique thing, though, about our hospital is that we also have a four-person mental health team. So, as we see the erosion of mental health services across the state as well, we’ve leaned into it and realized that this is something that our community really needs, and we try our best to plug all those holes. Unfortunately, the running joke is is that we could build a psych hospital and hire everybody that wants to come and work here and that psych hospital would be full and we’d have everybody extremely busy, but the resources just are absolutely not there and so we try to do what we can.
Hannah Shultz: That sounds like a pretty big hospital, actually, bigger than I had expected. Jim tells us about some of the challenges with delivering care in the city.
Jim Atty: So, Waverly is the best of both worlds in a sense. We are small and rural by definition, but a fairly affluent community for, again rural Iowa. Our major employers, our large insurance company, Wartburg College, and we have a very broad mix of manufacturers in the area. So, again, just a little bit more unique than you would see in other towns that are really based on one or two different industries or don’t have that good blue-white collar mix. Okay? When we start looking at some of the surrounding areas that we serve, you do run in to travel time issues, you run in to how can we bring the resources towards them. You’re hearing more about OB-GYN deserts and labor and delivery deserts that are starting to crop up all over the state. So, if you were to drive west, you can drive almost an hour and a half, if I’m not mistaken, before you find another labor and delivery unit. So, yet, I think that as you continue to move out further and further, you start to really find that there are gaps in services. Ambulance is another one. Are we getting good primary care out of these people or, like I said, if we have pregnant mom, are we able to get mom good prenatal care?
Hannah Shultz: Since 2000, at least 35 hospitals in Iowa have closed birthing units. Half of Iowa’s counties don’t have birthing centers.
Jim Atty: Well, last year, we delivered a woman who drove 45 minutes by herself in labor. I mean, the woman is in active labor. The only way she had to get here, she jumped in her car. Last week, we delivered a woman who drove a half hour away in the vestibule walking in our building. We laid her down and baby was on its way and we delivered right there. I mean, we did what we had to do, but that’s totally unsafe, and that’s just so scary for mom and for baby. God forbid, baby was breech or something else is not … Anyways, it’s very scary. I think some of the challenges in rural care delivery is we can struggle for identity to a degree. What do we want to be for our community? I don’t know that it makes sense that every rural hospital is everything to everybody. So, trying to figure out what we’re good at and making sure that what we’re doing we’re delivering at a very high quality and we’re delivering good patient care. We don’t have the depth and breadth of resources that a lot of other facilities have either. So, a larger facility might have a bank of 15 hospitalists that are taking rotations. We have three. If one were to get sick and be out for shift or God forbid longer, then we’re trying to cobble up a one in two hospitalists coverage as opposed to a one in three. So, the same thing goes for nursing. The same thing goes for radiology tech. The same thing goes for lab. The same thing goes across the board. So, we don’t have the breadth of staffing to be insulated, especially in a time of COVID where you can really take out your staffing at its knees and you can have somebody out for 14 days or I think they just changed the rules to 10 days, but to take one person out when we’re extremely reliant on that one person becomes extremely difficult. I think one of the good things, and I hope we get some momentum here is that we have been able to connect with our patients through telehealth and through whether it’s video conferencing or just by phone. The mental health population that we serve has an extremely high no show rate. By allowing us to deliver care through the tele methods, we’ve been able to reach them and reduce our no show rate to about zero over this time period. Now, Iowa, unfortunately, remains one of the laggards in that we do not have telehealth parity. So, we haven’t gotten paid for it except for the emergency declaration by the governor. So, I’m hoping that we can show that, “Look, this is a valuable service, and that mental health services are a little bit unique, and look at all the good that we’ve been able to do.” So, let’s see if that has some legs and if we can get something done in session next years.
Hannah Shultz: That no show rate is incredible. Expanding telehealth services long-term could really change the access issues we’ve heard about from all of our guests today. A quick update on Jim’s comment that Iowa doesn’t have telehealth parity, as I’m recording this, there’s a bill in the legislature to address telehealth reimbursement.
Jim Atty: Insurance companies just have to be won and pay for it. I mean, we’re one of the remaining states that won’t pay for it.
Hannah Shultz: Yeah. That’s ridiculous.
Jim Atty: When people can’t travel, and we can prove that there is good equity among whether you’re tele or in-person. I mean, it’s not for everything, right? You’re not get set somebody’s broken leg over a video, but if you can have your followup mental health conference with somebody, it’s great.
Hannah Shultz: Jim shared some of the benefits of working at a small local hospital.
Jim Atty: The biggest positive is that your community really knows who you are and is extremely supportive. If you’re doing the right thing, I think the community, if they love their community, they also love the hospital. They realize that we’re one of the foundational pieces. I always shy away from those that talk about the hospital being the economic driver and lean more towards us being an economic foundation. So, if you have good schools, you have good hospital, you have good public services, those should be the antecedents for somebody to want to come and move here, build their house, and start their life or better yet, for a business to come and want to set up shop here in your town. The hospital should be there so that everybody, it should be the springboard that everybody else has to help them grow. People realize that. We have the benefits of critical access, but are still large enough and affluent enough community that we can try new things and we can continue to try to invest in this facility. Whereas some smaller hospitals might not have that luxury.
Hannah Shultz: We often hear about shortages of providers. Jim shared his thoughts on how Waverly is able to attract physicians and other staff.
Jim Atty: I think a few different things. You’d be surprised how many people want to come back to this community. I’m not from here, but I completely understand why those that have been here want to end up here. So, we have quite a few providers that either grew up, went to high school here or came here and went to Wartburg and have said, “You know what? We’d like to come back to Waverly,” and we obviously welcome them with open arms. I think the other thing that we have going for us is that we have a compensation model that’s a little bit different. We pay our docs a salary as opposed to based on production. Why that’s important is what we end up doing is we end up valuing the quality of care that they give and we value the time that they spend with their patients, and we try not to get in the way of their ability to connect and work with a patient. So, I don’t want a timer going off in the back of their head that says, “You know what? I’ve already been in here 10 minutes. I got to hurry up to get to my next patient so that I can make sure that I maximize my paycheck.” No. We take that out and we put patient care first. I think our providers, once they get here, they really like that.
Hannah Shultz: I’ve been surprised in this conversation talking about the different services and specialties available at the Waverly Health Center. I asked Jim if there are things they do that folks in the community might be surprised to learn about.
Jim Atty: We have a surgeon who is doing gastric sleeves and he’s doing them with this minimally invasive procedure. He’s one of just a few in a very, very large geographic area that’s doing it. It’s extremely successful, and it is a fantastic weight loss option for those that have tried a few other things and haven’t found it successful. He truly changes lives everyday. One of the good things about that is that when he did come to us, it really got us to start thinking about, “What are we doing for healthy lifestyles earlier on?” It got us to think about, “Do we have our dietitians in place exercise science? Do we have people that are helping these individuals maybe curb some of their bad habits or get their weight under control before they get to that surgical option?” We feel like when he was here, he really got us thinking about putting the pieces in place so that we offer a very wide array of weight loss options. Ultimately, if those don’t work, we have the surgical option at the end that hopefully gives that individual the tool to be successful. I think the other thing that you’d be surprised with is the compassionate care that’s delivered. I know a lot of places see that, but, really, we’ve been awarded for it many times over the years, and continually our providers do put that, our providers and our staff, excuse me, really do make that a key focus in their day-to-day work.
Hannah Shultz: Jim shares how the hospital works with public health.
Jim Atty: Partnership is primarily with Bremer County public health. So, most recently, making sure to keep the lines of communication open with the public health departments. They’re getting a lot of information. We’re getting a lot of information. They have resources. We have resources. So, when dealing with this pandemic, we were really trying to really just circle our wagons and say, “Okay. So, what do you guys have here? What do we have here? What should we do in this situation?” One of the successes that we have was we had a countywide testing that was set up by public health and that we helped with, but we felt like it was a good idea. Emergency management came in to help as well, but just trying to figure out who’s getting what information and what resources. I know the state is trying, but it still seems like information and resources are extremely fragmented. So, it does take all of us to come together and try to figure things out. They work as a good connector with the nursing homes, and with the schools as well. So, some of our areas that we were concerned with early on, early on the spring, where we’re seeing outbreaks. We’re seeing them in nursing homes and we’re seeing them potentially on collage campuses. That’s what we’re worried about this fall. While we did see some spikes, felt like having all of us on the same page and public health being really a good connector there helped us work together to have good plans in place, so that if there was a spike that we could back down.
Hannah Shultz: We haven’t directly talked about COVID-19 much in this series, not because it isn’t important or front of mind, but because we want to highlight the work, strengths, challenges of rural life in general. However, it would be disingenuous to talk with the CEO of an independent critical access hospital without talking about the pandemic. So, we’re going to come at it head on now. Jim talks about how they initially collaborated with other health centers and stakeholders.
Jim Atty: Number one, we were able to collaborate with other community partners to make sure that we really did have a good response with the nursing home, with the college, with the schools, and then other businesses as they were looking to implement some changes. I think the other part that was extremely interesting about all this is that the competitive barriers among the other hospitals really did come down. We found that everybody knew. We all realized very quickly that a surge in Waverly was going to affect Grundy and Waterloo and Sumner and Independence and everybody in a large area. So, we began talking about search planning as a team, and more as a region, and less as a whose banner is our hospital under. It was very refreshing and it was just refreshing to talk through that with everybody else. So, we had some very detailed plans on what would happen if, say, Grundy Hospital had a major outbreak. Their hospital is overrun with patients. Quite frankly, like most rural hospitals like ourselves, we wouldn’t be able to put 20 people on ventilators. How are we going to respond together? Being led by Allen Hospital, we had a really good plan that would allow us to help one another out. So, that was very refreshing, and I really do appreciate all of those conversations.
Hannah Shultz: After all the planning and collaboration, Jim said they have hit capacity.
Jim Atty: We’ve hit capacity a few times. It’s very hard. I mean, we’re not accustomed to being at that level. Again, we don’t have the redundancy, the staff redundancies that a larger hospital have. We don’t have 10 nurses waiting in the wings that we can transfer over to a particular department. We have the nurses on the floor. We have the one hospitalist. So, we’re constantly monitoring and we’re constantly trying to figure out what’s coming next and trying to anticipate so that we can move what little pieces we have to move around. Our staff are tired. They’ve been working extremely hard. We have nothing to offer our staff anymore. So, we’re constantly going back to the well and saying, “Look, we need you to work one more shift. We need you to work overnight today. We need you to stay for a couple more hours.” I’m just very thankful that our staff has been as willing to really run into harm’s way, as you’ve heard, and maybe minimize their time with their families, so that they can make sure that the hospital can continue to respond to the issues in the community.
Hannah Shultz: Hospitals hitting capacity has been in the news quite a bit, but Jim explains what happens when they reach that limit.
Jim Atty: When our floor is completely full, and they need care, typically, what happens is we put out a call to the local EMS departments and say, “We can’t take any more inpatient. We can’t take any more inpatients.” It’s usually not a big deal because if we’re having a surge of patients pre-COVID, it was isolated to our area and then you would be able to get somebody in a bed somewhere else. So, our ambulance would be able to take the individual on our emergency room or bypasses just right way and head right to the next emergency room and find a hospital bed. What became difficult during COVID was there were no hospital beds statewide. At one point, we took the last ICU bed at Mercy Des Moines, and then they were shut down for the entire state. So, we were taking patients about two and a half hours from our hospital to another hospital trying to just find them a place to be cared for. So, when that happens, we really did start running into some of those pandemic measures. We’re keeping people in the emergency room much longer than we wanted to. We’re trying to discharge to a home or to a nursing home with some special instructions and the triaging became much more difficult. So, if push were to have come to shove and if we were to had take a real drastic measure, we would have shut down a majority of our other services and started housing patients down in our surgical suites, and potentially in other locations within the hospital. That’s something that we want to do. Ultimately, it is not as safe as being in a hospital bed, but it’s still better than having a line of people who are having heart attacks or who are in respiratory distress standing in line in our emergency room door waiting for a bed.
Hannah Shultz: Think about what it means for a moment to have to go two and a half hours to the nearest ICU. That’s a very long way. Now, we’re in the middle of winter. As I record this, there’s a blizzard outside of my window. So, that two and a half hours will take even longer. When COVID cases surged, all patients are impacted.
Jim Atty: The way it was working, we were housing people in our emergency room for hours at a time. I don’t think people realize that we’re at a point with COVID where, yes, there’s still people dying and still people getting sick, but being overrun in the hospital with this many people with pneumonias that we’re trying to take care of or who have to be in isolation and takes that much longer to take care of them because you have to don and doff basically a whole biohazard suit to go into their room. That means that the person next door who is having heart palpitations isn’t get care as timely or isn’t getting transferred as timely. It’s not as simple as just these are the people that are dying from COVID. No. We have ancillary deaths because we, as a system, don’t have the resources to care for everybody at the same time. We have people that are dying because their care has been delayed. You have somebody that’s having a stroke and that person is coming to our hospital and our emergency room is full and our floor is full, and we’re at capacity, then what? I mean, where did the stroke patient go? So, stroke patient then gets in the car and has to go 45 minutes up to Mason City or has to go somewhere else before we can get them care. I mean, we’re going to try to stabilize them the best we can, but just like everywhere, you can’t take care of absolutely everybody right now to the level that they deserve.
Hannah Shultz: I’m going to repeat that. You can’t take care of everyone right now to the level that they deserve. I have so much respect and gratitude for Jim, all of his colleagues and all of the public health professionals who have worked tirelessly for a year now, some without a single day off since early March 2020 to take care of patients and do whatever they can to keep our community safe. I’m going to let Jim wrap up today’s episode with what he wishes people understood about COVID-19.
Jim Atty: I think there’s two things. I want people, so anybody who still feels like this is a joke and a hoax and overblown, it is not. There are people that are dying at our hospital of this everyday. There are staff here that are holding that person’s hand and watching them die every single day. Okay? We have staff members here who are working extremely hard to keep the doors of this hospital open so that we can respond and save those that we can save, but the hard work still needs to be done outside of here. So, remember to wear your mask and social distance and take those things seriously so that we can continue to keep this at bay.
Hannah Shultz: Thank you for tuning in to this episode of Share Public Health. Thank you to the Injury Prevention Research Center, Iowa Center for Agricultural Safety and Health, the Healthier Workforce Center of the Midwest, the Heartland Center for Occupational Health and Safety, the Great Plains Center for Agricultural Health, the Midwestern Public Health Training Center, the Prevention Research Center for Rural Health, and the Rural Policy Research Institute.
Hannah Shultz: The theme song for this series is Walk Along John. It’s performed by Al Murphy on fiddle, Mark Janssen on mandolin, Brandy Janssen on banjo, Warren Hamlin on guitar and Aletta Murphy on bass. Al learned these songs from a fiddler named Albert Spray, who is from Kahoka, Missouri.
Hannah Shultz: A transcript evaluation and discussion guide for this episode are available at mphtc.org and in the podcast notes.