Despite challenges, hospitals are vital to rural communities, health care experts say

Nov. 24--GRAFTON, N.D. -- When a patient comes in for an appointment at Unity Medical Center, it can feel like medical staff are treating a family member, Director of Nursing Jenny Holand said.

"All of our staff are from small communities, or most of them, and they all know how important it is to have a health care facility in the community to take care of not only their loved ones but all of our friends, neighbors and community," she said. "They become our extended family. You get to know patients on a first-name basis. They are not just a number. They genuinely care about each patient they encounter."

The sentiment was shared by several UMC executives and managing staff as the Herald discussed how the facility was preparing for updates to the Grafton facility, including a proposed $5.5 million expansion that would convert operating suites into an emergency department, add a surgery area with larger operating rooms and relocate the physical therapy department from the second floor to the front of the building, providing better access for patients. The project is expected to begin sometime next year with a finish date to follow 12 to 15 months later, CEO Alan O'Neil previously told the Herald.

The expansion is a way of staying competitive with urban hospitals while providing up-to-date services to patients, he said. Technological advancements have changed how hospitals do business, he said, and local, rural hospitals offer a service that, if they didn't exist, some patients would have to drive an hour to get to.

When asked what the region without rural hospitals would look like, he and his co-workers emphasized how important rural hospitals are to residents in small-town communities, adding "it would be devastating" if they disappeared.

"We have cases every day that are life-saving," he said. "It would cause a whole population that would have to travel for everything. ... As you know, traveling in North Dakota can be a challenge, especially in the winter."

Local appeal

North Dakota has 36 critical access hospitals, and those facilities have a significant impact on the economic climate of communities, said Brad Gibbens, deputy director of the Center for Rural Health at UND. On average, each hospital has an economic impact of $6.4 million, whether in primary or secondary effects, he said.

Hospitals have created dozens of jobs for rural cities and often are some of the largest employers in the surrounding area while providing services for remote areas.

UMC, which employs about 120, has a footprint that reaches at least 20 miles in all directions, sometimes farther, O'Neil said. The hospital sometimes serves Canadians who cannot get into hospitals quickly north of the border.

Access to a hospital is one reason people choose to live in a community, O'Neil said.

"It's the backbone of a community," he said, adding Grafton has had a hospital for more than a century.

Christopher Wyatt, CEO for Cavalier County Memorial Hospital and Clinics, agreed, saying North Dakota would see a mass migration to bigger cities if hospitals didn't exist. The hospital in Langdon, N.D., with roughly 110 staff members serves Cavalier, Pembina, Ramsey, Walsh and Towner counties, he said.

"The people sometimes don't realize how important a hospital is to a community," he said. "People want to be in an area ... where they can get that immediate care because accidents happen."

Rural hospitals in North Dakota offer more than just standard services, Gibbens said, adding 35 critical access hospitals own another health care organization, whether it be nursing homes, ambulances, assisted living centers or clinics.

He added residents in smaller communities feel they are receiving equivalent, if not better, care from rural hospitals compared with residents who seek health care in urban areas.

"The argument is, if a rural hospital closes in North Dakota, it's not just a hospital closing," he said. "Rural hospitals are more than an employer, and even more than a provider of health care to take care of people. Rural hospitals are also a source of community identity and pride."

Challenges

There is an array of challenges rural hospitals face, especially in the face of populations that are shifting toward urban life. O'Neil said 20 percent of the U.S. population, or between 60 million and 65 million people, live in rural areas.

As younger people move to bigger cities, hospitals in North Dakota's smaller towns are seeing patients who are older and have higher care needs, O'Neil said. On top of that, shortages in staff--from nurses to physicians--make it hard at times to keep up with demand.

In community needs assessments compiled by the Center for Rural Health, trends for North Dakota include providing services for aging populations, access to needed equipment and facility updates and higher costs for health insurance.

Federal reimbursements help cover expenses for hospitals, and facilities receive funds through Medicare and Medicaid, but those funds have been on the decline in recent years.

It's no secret hospitals in rural communities struggle financially, but hospitals in North Dakota have seen gains in operating and net margins, Gibbens said. North Dakota's hospitals had an operating margin of negative 1.5 in 2015, compared with negative 5.1 in 2014, he said. The total margin rebounded to 3.1 last year, which was the first time since the rural health center has been looking at operating figures that more hospitals--19--in North Dakota saw a profit than a loss--17.

He attributed that to a federal drug program that stretches financial resources for eligible patients, Medicaid expansion, local tax support and foundations.

Wyatt said his hospital is operating in the black because it has looked at ways to tighten its belt.

"We have to make sure we're operating in the black, and that's a hard thing in a small, rural community whenever people have a perception they have to drive to Grand Forks, Bismarck or Fargo to get the same quality care," he said. "We're working diligently to show them you can still get that quality care at your local hospital as you can in the cities."

Staying up to date

Despite the challenges, local hospitals have done what they can to stay up to date.

If a facility can't afford to purchase equipment, a hospital can partner with larger health care providers to bring those services to communities, as UMC and Cavalier County do, O'Neil and Wyatt said. When necessary, hospitals look to update their facilities, like UMC did when it started its $550,000 project this fall to renovate its clinic to provide more privacy for its patients. Cavalier County updated its hospital several years ago in a multi-million-dollar project, Wyatt said. The clinic also could see updates in the near future. That would include a pediatric room and other features of the clinic, he said.

Gibbens said there is an ongoing effort for rural hospitals to stay up to date, even if they fall behind urban hospitals' technologies.

Though it is required by the Affordable Care Act, all nonprofit hospitals in North Dakota, including UMC and Cavalier County, have actively sought public input from residents to determine the community's needs and concerns. Cavalier County has the approach of making decisions that have the best outcome for associates, patients and finances, Wyatt said.

"I think we are making steps in the right direction," he said of his hospital providing up-to-date services. "We are all shifting to value-based medicine."

He was referring to preventative practices as opposed to reactive medical services, adding hospitals, including those in rural areas, are focused on keeping their communities healthy.

"We're putting a bigger emphasis on what can we do to keep you out of the hospital," he said.

At the end of the day, staff at local hospitals do everything they can to provide outstanding services for its community members, O'Neil said, adding many nurses, doctors and staff members take the extra step for the people they know.

"You tend to go the extra mile for someone you are going to bump into on the street next week or see in church," he said.

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