Tagged Rural Medicine

How Helping Patients Get Good Care At Home Helps Rural Hospitals Survive

Rural hospitals close when they don’t have enough paying patients to care for, but they’re also dinged when the same patients show up over and over again. That puts outlying medical facilities in the precarious position of needing to avoid repeat customers.

Charlotte Potts is the type of patient some hospitals try to avoid. She lives in Livingston, Tenn. — a town of 4,000, tucked between rolling hills of the Cumberland Plateau.

“I’ve only had five heart attacks,” Potts said recently with a laugh. “I’ve had carotid artery surgery. Shall we go on? Just a few minor things.” She joked that she’s “a walking stent.”

The heart trouble has affected the way Potts deals with her health problems. She spends much of her day in a recliner in her apartment, tethered to a pulsing oxygen machine, and listening to the radio.

Fortunately, her apartment sits within spitting distance of Livingston Regional Hospital — a 114-bed facility large enough to have a dedicated cardiac unit. But the hospital doesn’t want to see her every time her heart flutters.

So, the last time she landed in the ER, they helped her connect with a few companies that could provide care at home.

“If I’m going to have certain things going on here in my chest, I call for help, and they’re there,” Potts said of the home care team she chose.

Livingston Regional Hospital has cut readmissions by more than four percent in the last five years — more than any other rural hospital in Tennessee.(Shalina Chatlani/WPLN)

A New Era In Hospital Management

There were days when the hospital might have viewed a home health agency as a competitor. Not anymore.

“When I started this almost 40 years ago, the mission was different,” said Tim McGill, CEO of Livingston Regional. “We wanted patients in the hospital. That was the incentive. We were paid for it. Now you’re not.”

Hospitals used to run on a so-called fee-for-service model with virtually no limit to how many times they could see a patient. But, under pressure from private and government insurance programs, that model is transitioning to one in which hospitals are rewarded for safety and efficiency — which often results in a patient spending less time in the hospital.

Under the Affordable Care Act, Medicare began to ding hospitals if too many patients are readmitted to any hospital within 30 days of discharge. The measure is broadly unpopular with the hospital industry, since so much falls outside a hospital’s control. Medicare has even walked back the rules for safety-net facilities, which tend to treat a sicker population.

The penalty is meant to encourage hospitals to get it right the first time. In Livingston, the hospital operates on the thinnest of margins — just 0.2 percent in the most recent figures. And “readmissions” have been a drag on the bottom line.

One in 5 patients with heart failure was back within the month. The hospital has paid the maximum penalty in some years — nearly $200,000. So leaders started asking a basic, unifying question of other providers in town, McGill said: “What can we do together so they’ll stay out of the hospital and stay healthier in their home setting? That’s where the work is.”

Collaborating Instead Of Competing

The work took the form of quarterly lunch meetings at the local library.

Mary Ann Stockton, a nurse at the hospital, invites all the home health agencies as well as hospice providers and the leaders of nursing homes.

At one meeting, she applauded the other providers for increasingly meeting patients inside the hospital before they’re discharged. She said it helps patients and families accept these home health workers.

“We know in our area people don’t like to have a total stranger come into their home,” she said.

The group brainstormed how to generate the same kind of acceptance for hospice care, which — as one doctor in the meeting put it — some families view as “assisted suicide.”

And on this day, the group spent much of its time reviewing the value of flu shots, especially for the staff in nursing homes. Stockton said elderly patients with bad lungs become a hospital emergency room’s “frequent flyers.”

“Flu starts off, goes into pneumonia, COPD exacerbation — and they are a revolving door in our hospital,” Stockton said. “They’re hitting that ER a couple of times a week.”

Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming ER regulars.

Livingston’s parent company, LifePoint Health, is launching this community approach in many of its 80-or-so markets, which are primarily in the Southeast and almost all rural. Cindy Chamness, a LifePoint vice president, helps hospitals find willing partners.

“We were very frustrated for many years,” Chamness said, “because we weren’t able to impact readmissions just working on it by ourselves, as a hospital.”

‘Are We Saving Ourselves Right Out Of Business?’

The solution looks different from one town to another. In Lake Havasu, Ariz., paramedics now visit discharged patients to make sure they’re following doctors’ orders. The house calls also cut down on government-funded ambulance rides.

It’s not just rural hospitals — all hospitals can be penalized for readmissions now. And threatening the bottom line in that way does seem to be effective. Readmissions have been falling across the board, according to the latest research.

But rural hospitals, which already treat fewer patients than urban hospitals, wonder if they’ll have enough patients to survive, said Michael Topchik of the Chartis Center for Rural Health.

“[A] CEO from Montana said to me, ‘The problem is, when we do the right thing, are we saving ourselves right out of business?’” Topchik said.

The focus on cutting readmissions — by definition — cuts overall admissions too, he noted.

“So, this is the real inherent tension and challenge: Hospitals get reimbursed for doing ‘sick care,’” Topchik said. “But more and more they’re being asked to do population health, and really focus on ‘wellness.’”

To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.

There is also some immediate financial upside to reducing readmissions: Livingston Regional has cut readmissions more than any other rural hospital in Tennessee and even the nation, according to data compiled by Chartis.

As a result, the hospital’s Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements — down from the maximum of 3 percent, which was roughly $200,000 a year.

That’s all because patients like Charlotte Potts now can safely stay home.

“I got a real bad tightness in the chest,” Potts recalled about a recent episode. She’d questioned whether to call an ambulance. “I was very uncertain about what was going on.”

But she phoned her home health agency, took a nitroglycerin pill as the agency advised and, instead of going to the ER, was able to get back to sleep.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

After Bitter Closure, Rural Texas Hospital Defies The Norm And Reopens

Five months ago, the 6,500 residents of Crockett, Texas, witnessed a bit of a resurrection — at least in rural hospital terms.

A little more than a year after the local hospital shut its doors, the 25-bed facility reopened its emergency department, inpatient beds and some related services, albeit on a smaller scale.

Without a hospital, residents of Crockett, located 120 miles north of Houston, were 35 miles away along rural roads from the next closest hospital when a medical crisis struck, said Dr. Bob Grier, board president of the Houston County Hospital District, which is the county’s governmental authority that oversees Crockett, a public hospital. “Someone falls off the roof. A heart attack. A stroke. A diabetic coma. Start naming these rather serious things and health care is known for its golden hour,” he said.

The late-July reopening of the newly named Crockett Medical Center makes it a bit of a unicorn in a state that has led nationally in rural hospital closures. Since January 2010, 17 of the 94 shuttered hospitals have been in Texas, including two that closed in December, according to data from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.

But Crockett’s story also reflects some of the challenges faced by rural hospitals everywhere. Board members frequently have limited background in health care management and yet are responsible for making financial decisions. Add to that mix a Lone Star State resistance to raising local property taxes. An effort to increase the county’s 15 cents per $100 property valuation for the hospital district has been defeated twice since the hospital closed.

And a small rural hospital like Crockett’s has “no leverage” when negotiating reimbursement rates with insurers, Grier repeatedly points out.

The tough reality is that too many rural hospitals in Texas and elsewhere, when negotiating with insurers and other financial players, “are almost always negotiating from weakness and sometimes from literally leaning out over the edge of the [survival] cliff,” agreed Dr. Nancy Dickey, executive director of the A&M Rural and Community Health Institute at Texas A&M Health Science Center.

Rural communities must think more creatively about how to meet at least some of their health needs without a traditional hospital, whether it’s forming partnerships with nearby towns or expanding telemedicine, Dickey said. “There is little doubt in my mind that many of these communities are going to see their hospitals close,” she said, “and are not going to be able to make an economic case to reopen them.”

The A&M institute, which in December published a report looking at these challenges for three Texas communities, recently landed a $4 million, five-year federal grant to help rural hospitals nationwide keep their doors open or find other ways to maintain local health care.

Demographics And Decisions

The financial headwinds have been particularly fierce in Texas, one of 14 states that has not expanded Medicaid eligibility after the passage of the Affordable Care Act. “That makes a huge difference,” said John Henderson, chief executive officer of the Texas Organization of Rural & Community Hospitals, known in Texas rural circles as TORCH. “But that doesn’t change the reality that we aren’t going to do it.”

Leading up to the state’s biennial legislative session, which begins in January, rural leaders are making the case that state legislators need to take steps to bolster the state’s 161 rural hospitals, starting with rectifying underpayments for Medicaid patients. As the state’s program has transitioned to managed care, over time reimbursements have shrunk to the point that rural hospitals are losing as much as $60 million annually, according to TORCH officials, who cite state data.

They also support a congressional bill, HR 5678, that would make it easier for rural hospitals to close their inpatient beds but retain some services, such as an emergency room and primary care clinic. Under current federal regulations, facilities that make such a move are no longer considered a hospital and can’t be reimbursed by Medicare and Medicaid at hospital rates, which are often higher than payments to clinics or individual doctors. Those lower rates make it harder for stripped-down facilities to keep up their operations, said Don McBeath, TORCH’s director of government relations.

Crockett’s hospital, then called Timberlands Healthcare, abruptly shut down in summer 2017 after just a few weeks’ notice from its management company, Texas-based Little River Healthcare. Little River, which was also the subject of an analysis by Modern Healthcare that showed several of its hospitals engaged in unusually high laboratory billing for out-of-state patients, has since filed for bankruptcy. Two other rural hospitals affiliated with Little River closed their doors in December

As it struggled to stay open, Crockett’s hospital had been treating a population that was increasingly poor and aging, according to Texas A&M’s report. The researchers describe in the report — Crockett is “community 1” among three communities featured — that the hospital was overstaffed with more than 200 employees given its daily average census of three hospitalized patients. Also, they wrote, board members should have more closely questioned the management company. The board said they were given data at each meeting, “but that data did not suggest the imminent demise of the hospital,” the report’s authors wrote.

Fighting The Closure Tide

Leaders in Crockett tried to capture the interest of other hospital systems to reopen and manage the facility, without success, Grier said. Along with staffers losing their jobs, the community knew it would be more difficult to persuade people to relocate or retire to the area without a hospital nearby, he said.

Every weekday at noon for weeks on end, a small group of two to 20 people gathered beneath the hospital’s front portico to pray for some avenue to reopen, Grier said. Then, as the odds looked increasingly long, they got a call out of the blue from two Austin-based doctors. “I feel God was involved,” Grier said. “They have told us that they were looking for some kind of a larger investment.”

Those initial conversations resulted in a five-year lease arrangement between the hospital district and the management company, operating as Crockett Medical Center LLC.

The two physicians, Dr. Kelly Tjelmeland and Dr. Subir Chhikara, are listed on Crockett Medical Center’s website as chairman and president, respectively. They failed to respond to requests for comment about their plans for the hospital. But in a presentation to the board before the lease was signed, they said that one of their goals was to get the facility classified as a critical access hospital, which enables a higher reimbursement for Medicare patients.

Along with operating a primary care clinic and 24/7 emergency room, Crockett Medical Center staffs a handful of hospital beds for patients who need more limited medical treatment, such as heart monitoring or intravenous antibiotics, Grier said. But when the Crockett hospital reopened, it didn’t resume delivering babies. Only 66 of Texas rural hospitals still provide obstetrics services, according to McBeath.

Eliminating baby deliveries was one possibility on the table at another rural hospital if that hospital CEO hadn’t pulled off the sort of Texas miracle that Crockett has yet to achieve — persuading local voters to support a tax increase. Adam Willmann, CEO of 25-bed Goodall-Witcher Hospital Authority, northwest of Waco, said that he and others made the case in dozens of meetings that a hospital property tax was needed to support the financially struggling hospital.

In November, 58 percent of the county’s voters backed the new tax, despite the community’s political leanings. During that same election, 80 percent voted to re-elect Republican Sen. Ted Cruz.

“They want to be 5 minutes, 15 minutes from an ER and not 35 miles down the road,” Willmann said, referring to the nearest hospitals in Waco. “And they’re willing to pay a little more for it.”