Healthcare Leadership and Rural Communities: Challenges, Strategies, and Solutions

HEALTHCARE LEADERSHIP AND RURAL COMMUNITIES

Challenges, Strategies, and Solutions

ACHE Management Series Editorial Board

Kris M. Drake, FACHE, Chair

Ingham Community Health Centers

Jorge Amaro, FACHE

A3i, Inc.

Roddex G. Barlow, FACHE

The Hospitals of Providence Memorial Campus

Tyler A. Bauer

NorthShore University HealthSystem

Jeffrey T. Hodges, MBA, RT, FACHE

Reston Hospital Center – HCA Virginia

Shanna Johnson, FACHE

Henry Ford West Bloomfield Hospital

Faith Needleman, MSN, RN

Mitali Paul, FACHE

Houston Methodist Specialty Physicians Group

Christopher L. Queen, FACHE

GE HealthCare – Imaging

Michael Reid, FACHE

Eastern Maine Medical Center

CDR Lisa A. White, FACHE

Navy Medicine Professional Development Center

Nichole C. Wilson, DPT, MBA, FACHE

Indiana University Health

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This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the author and do not represent the official positions of the American College of Healthcare Executives or the Foundation of the American College of Healthcare Executives.

Copyright © 2023 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Names: Putnam, Tim (Timothy), author. | King, Nikki, author. | Auxier, William R., author. Title: Healthcare leadership and rural communities : challenges, strategies, and solutions / Tim Putnam, Nikki King, and Bill Auxier. Other titles: Management series (Ann Arbor, Mich.) Description: Chicago : Health Administration Press, 2023. | Series: ACHE management series | Includes bibliographical references. | Summary: Leaders of rural healthcare organizations confront unique challenges. Payment systems, power dynamics, labor availability, and accessible resources differ considerably between rural and urban areas. Healthcare Leadership and Rural Communities outlines what it takes to manage care in a rural community and provides advice on overcoming the common challenges that healthcare executives confront. The authors provide candid insights gained from their experience as rural healthcare managers and their work with leaders in the field – Provided by publisher.

Identifiers: LCCN 2023001884 | ISBN 9781640553750 (trade paperback) | ISBN 9781640553743 (epub) | ISBN 9781640553989 (ebook)

Subjects: MESH: Rural Health Services—organization & administration | Leadership | BISAC: MEDICAL / Hospital Administration & Care | BUSINESS & ECONOMICS / Industries / Healthcare

Classification: LCC RA771.5 | NLM WA 390 | DDC 362.1/04257—dc23/eng/20230526 LC record available at https://lccn.loc.gov/2023001884

The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ♾ ™

Acquisitions editor: La’Toya Carter; Manuscript editor: Joe Pixler; Cover designer: Mark Oberkrom; Layout: Integra

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This book is dedicated to the people in rural healthcare who selflessly serve their neighbors in small towns across America. They wish for no personal honor or recognition, but instead want only to make the world better for those they serve. Healthcare leaders should consider themselves lucky if they get a chance to work with people who are driven to make life better for people in rural America.

In writing this book, my favorite conversations were with clinicians, community members, staff, and other leaders who were frustrated with the status quo and knew healthcare could be better. They freely shared their ideas and concepts to help move the care we provide forward.

Rural healthcare is filled with heroes and villains, the humble and the proud . . . people seeking money and glory as well as those dedicated to serving their fellow man. Most truly want to make a positive impact on their communities, and I consider myself blessed to work with them. They make rural America a very special place.

Tim Putnam, DHA, MBA, FACHE

Contents

Preface

Introduction

Chapter 1. The Unique Realities of Rural Healthcare Leadership

Chapter 2. Quality Matters

Chapter 3. Finances and Funding

Chapter 4. Recruiting, Developing, and Retaining Talent

Chapter 5. Community Health Partnerships

Chapter 6. Relationships with Tertiary Health Systems

Chapter 7. Community Messaging

Chapter 8. Medical Staff Relations

Chapter 9. Rural Healthcare Governance

Chapter 10. Behavioral and Addiction Care

Chapter 11. Crisis Preparation and Response

Chapter 12. Healthcare Equity: A Rural Perspective

Chapter 13. Why Rural Healthcare Leaders Get Fired

Case Studies

Index

About the Authors

Preface

RURAL HEALTH LEADERSHIP is not for the faint of heart! Leading rural healthcare organizations is challenging at the best of times. Rural leaders deal with limited resources, difficulty in recruiting clinical staff, and a distant voice in state and federal policy decisions. And everyone in a small town—patients, providers, and community leaders—seems to know everyone else’s business. Compounding these factors is the pressure from knowing that failure means lives and livelihoods are at stake and that closure of a rural health facility can signal the slow and steady decline of an entire community.

This book addresses the challenges faced by rural leaders from a practical perspective. It offers guidance on how to work through the predicaments that leaders find themselves in and shares practical solutions.

Healthcare teams, boards, providers, and community leaders can use this book as a resource to learn together. The information is presented in a way that can prompt shared reflection on how to apply it to their specific circumstances. Seeing parallels between scenarios and case studies described in the book and local challenges can be a good way to open a conversation about a difficult topic and then work toward a solution.

Rural healthcare desperately needs good leaders. People who are committed to making a positive impact on the lives of their neighbors will find the calling of rural health leadership personally and professionally impactful and rewarding. Hopefully, this book will give them the guidance and support they will need.

Introduction

MANY PEOPLE WORKING in rural healthcare struggle with the difficulties associated with serving the needs of small communities. There is a simple reason the task seems so hard: It is very hard. Payment models designed for high-volume urban centers, regulations and standards written by people who work in huge academic settings, and limited resources are just a few of the myriad reasons that rural medical institutions struggle to survive.

Even as rural hospitals are shuttered at a quickening pace, many that remain open must discontinue vital services that have a negative return on investment like obstetrics to stay in business. Meanwhile, rural independent physicians who are unable to make money with their practices have closed their offices and joined the local clinic or hospital. This consolidation of services figuratively puts all the community’s healthcare eggs into one basket, so if its lone organization closes, the staff has no viable option but to leave town for employment—and the community loses all local access to care.

Rural healthcare leaders are under tremendous pressure to maintain high-quality care and financial viability. They may be seen as money-grubbing administrators who deprive valiant clinicians of the resources they need to heal their patients, and yet the failure of the business will signal the inevitable decline of its community.

Without a doubt, the job of a rural healthcare leader is not for the faint of heart. The people who choose to take on the role and take it seriously are warriors. They are committed to making a positive impact on the community they serve. To help them demonstrate their commitment, this book outlines practical strategies and tactics. Six themes predominate.

Technology brings opportunities and challenges. Changes in healthcare delivery have significant implications (some positive, some negative) for rural healthcare. Telehealth and telemedicine can bring advanced care to remote areas where subspecialties, imaging technology, proton beams, and robotic surgery would not otherwise be available. Because scale and expense requirements effectively eliminate the ability of rural organizations to possess every tool and capability they need, rural healthcare leaders must collaborate with the organizations that have them.

Everyone works better together. Communities can thrive when everyone works together. Rural healthcare leaders must be teambuilders. When emergency medical services (EMS) providers, hospitals, clinics, long-term care providers, and employers all work exclusively in their self-interests, the consequences will likely be negative for all. If an employer opts to save money by going with a health plan’s preferred network of out-of-town providers, local clinics and practices may be forced to scale back services or close.

Resources are limited, by design. The way healthcare costs are reimbursed in the United States effectively disenfranchises rural care delivery. The costs to prepare for whatever crisis might occur are not reimbursed; they are only paid for care provided—and there are generally too few patients to cover the costs.

Readiness is essential regardless of low volume. Despite the reality of inconsistent and somewhat unpredictable volume that rural healthcare organizations face, every program or service requires some level of capital investment and ongoing operational cost support. Maintaining rural EMS with ambulance, equipment, and staff is expensive, and every day that goes by without a single call is a day without revenue to support the service. However, not providing quality service comes at a greater human cost to the community.

It’s good to know who’s who. In a small town, familial and social connections are abundant and not always obvious. Making a hiring decision based solely on merit can have negative repercussions if people with deep roots in the community perceive any disrespect. Successful leaders must be aware of these connections so they can anticipate the impact of their decisions on themselves and their organization.

The joys of experiencing and improving rural life. Despite all the challenges of rural healthcare, its leaders enjoy the unique ability to make a huge impact on their friends and neighbors—to improve the quality of life for people they know and care about.

There is a lot of rural across the United States. While many similarities exist, no two rural communities are exactly alike. Small towns pride themselves on individuality, and rural healthcare organizations tend to follow that attitude.

While reading this book, it’s important to keep in mind that each local situation is unique. It’s advisable to share the ideas in this book with other stakeholders to see what rings true or how situations may differ. Clinicians may disagree with a particular perspective, while administrators wholeheartedly concur. The reflection points at the end of each chapter are intended to prompt lively discussions of common challenges and lead to collaborative solutions.

CHAPTER 1

The Unique Realities of Rural Healthcare Leadership

Bill Auxier, PhD, and Tim Putnam, DHA, MBA, FACHE

BOB, THE HOSPITAL CEO, was filling up his pickup truck at the local gas station when the mother of one of the girls on his daughter’s softball team approached him in a shy, awkward way. After saying hello, she asked, Could you write a prescription for me? She knew he was the president of the hospital and assumed he was a physician. Bob replied that although he did work at the hospital, he was not a physician and could not write prescriptions. Who is your doctor? he asked helpfully. Let’s give them a call.

This scene illustrates a common experience for rural healthcare leaders: As the public face of healthcare in the community, they are recognized everywhere. Their unique status is also what makes them leaders in the community, even as they face extraordinary demands of providing healthcare services with limited resources. And yet, with these challenges of leadership come opportunities.

THE RURAL LEADERSHIP REALITY

Context is worth noting here: Every 3–4 weeks, another rural community loses its hospital, and as the number of hospitals in rural America continues to drop, the people who depend on them are getting older, poorer, and sicker on average than their urban counterparts (Foundation for Research on Equal Opportunity 2021). New rural healthcare leaders inherit that reality upon arrival in town, along with the opportunity to make an impact on these issues. They are in a special position to make sure that their communities continue to have access to the care they deserve.

How does a rural healthcare leader