Rural Health: "Think Small" (...rural hospitals.)

Aug 17, 2017

All year long, the Alabama Public Radio news team has been investigating the state’s rural healthcare system. One issue is hospitals. Seven rural counties in Alabama don’t have one, and one more county may be added to that list by the end of the month. John Paul Jones hospital in Wilcox County says it will close after sixty years. Five other rural hospitals have closed since the year 2010. Eighty percent of those that are left are operating in the red, in part due to Medicare which pays less in rural Alabama than almost anywhere else in the nation. APR’s Pat Duggins reports one possible remedy for the state’s rural hospital shortage is to think small…

“I think people in the United States of America just don’t realize that places like Perry County, Alabama still exist.”

If you want someone who’s happy with rural health care in Alabama, don’t ask Kendal Gilchrest. “We’ve actually lived in a third world country for a period of our lives," she says. "And there were more resources, and more networks of support for us as a family in that third world country, then there has been here.”

In case you were wondering which third world country… “The Dominican Republic," she responds.

Kendal, her husband Eric, and their three young children live in Marion. The Gilchrests work at Judson College. On the subject of dealing with rural health care, Eric has an example from just last week…

“My son falls out of bed, middle of the night, it’s two o’clock in the morning, and he wakes me up and he has blood rushing down his face, he had gashed his, the corner of his eye open, and there’s blood all over his face,” he recalls. “If we were living in a different area, you’d take him five minutes down the road, ten to fifteen minutes down the road, to get it stitched up and get it taken care of. It’s two o’clock in rural Alabama, what do you do?”

Between them, the Gilchrest’s have four masters degrees and a PHd. But, even that didn’t help them get around the fact that Perry County doesn’t have a hospital. The Alabama Rural Health Association says six other counties are in the same boat. When the only hospital in Wilcox County closes in a few weeks that will mean residents in eight Alabama counties could be asking questions like this one…

“Do you drive an hour and a half one way to gets some stitches, he may not even need stitches. Or, do you just put a Band-Aid on it, and wait it out, and see what happens. We waited it out to see what would happen,” says Gilchrest. “And the next day, he did need some glue, they glued it shut and it was okay. But, these are the sorts of decisions you’re making at two o’clock in the morning.”

Just one county to the north, things seem less tense. Joseph Marchant’s big concern is making sure two boys don’t fall off a four foot tall stone wall outside the Bibb Medical Center. Marchant is the CEO. This rural hospital in the town of Centreville in Bibb County is just twenty five miles north of Marion where the Gilchrests live, but it feels like world away… Along with the Hospital, Bibb Medical Center has a dental clinic and a nursing home. Marchant says finances are tight, but it works…

“I think our system here is a little different, because again we’re a little more unique than some because of the diversification that we have on our campus. Rural hospitals...we have some secret sauce, and can do things... we have to be lean because you can't stay in business in you're not."

And Marchant says his hospital isn’t among the eighty percent in Alabama operating in the red. Bibb Medical Center has thirty five hospital beds. Alabama will only certify hospitals with a minimum of fifteen and Perry County where the Gilchrests live doesn’t even have that.

“Unfortunately, they have to have fifteen in Alabama," says Dale Quinney. He’s executive director of the Alabama Rural Health Association. He’s looking for something in between the feast in Bibb County and the famine in Perry… “There are some communities that perhaps can afford a hospital, financially, their patients will make it profitable, that don’t need fifteen beds.”

That begs the question—how low can you go when it comes to the number of beds in a hospital?

“We had three," says Debbie Berry. She’s the director of operations at the Greene County Hospital in Leakesville, Mississippi. And, you heard right, she said three…

“But, when you have three beds, you wonder how are you going to make it?” she asks.

Dale Quinney says Leakesville does… “This hospital, fifty four employees, three beds, and as we speak it’s expanding to seven beds, is operating at a profit. So, it can be done in the right location.”

So, we hit the road to have a look. Leakesville is a three hour drive southwest of Tuscaloosa, or an hour northwest if you’re coming from Mobile. Once on the campus of Greene County Hospital, we head through a sliding glass door, and up to the reception desk.. That’s where we met Debbie Berry An automated lab unit processes blood samples from Greene County patient load. Berry says there’s a lot of samples to handle…

“It went from them seeing one or two a day, when we came here—we’re seeing three hundred and fifty now, a month,” says Berry. “So, our numbers have just climbed tremendously, but we’re offering so much more now than we did.”

What makes it all work? Joseph Marchant talked about the secret sauce at his hospital. The sauce at Debbie Berry’s is what patients see when they walk in the door…

“We’re the first hospital in the state to have only nurse practitioners in their hospital," she says. "We don’t have any doctors in our facility.” And it’s that formula of fewer beds and no doctors that’s the rub for regulators in Alabama.

“I think it’s a bit too simplistic,” says Dr. Tom Geary with the Alabama Department of Public Health. He handles regulatory affairs, so he’s familiar with how the business model of Leakesville’s hospital will be received in Alabama.

“It’s more complex on top of something that’s already complicated.” Geary says the fifteen bed minimum for rural hospitals in Alabama is due to state red tape. It means these facilities can expand if they need to, without a state relicensing process that can take years…

“And so, this is a compromise situation of making a difficult situation at least feasible for smaller hospitals to get at least fifteen beds functioning.”

And when it comes to areas like Perry County that have no hospital at all, Dr. Geary has an idea on that as well…

“Number one, would be to eliminate a lot of the rural hospitals…to utilize all of the land, the building, the services, the equipment, the personnel they have, as a highly efficient outpatient urgent care center.”

Urgent care centers treat people on the spot and either send them home or to bigger hospitals. On the subject of nurse practitioners doing the work of doctors, Geary says Alabama prefers physicians who directly supervise nurses—unlike what Leakesville does.

Which takes us back to the town of Marion, and Judson College which is one of the big employers in Perry County. The voices of its college choir are one of the few signs of hope in a situation that seems to otherwise bleak.

“It’s hard for us to support each other, because we’re kind of just surviving. says Kendal Gilchrest. She and her family, there’s no clear sign that anything will get better here. “I think once we leave here, we will…I think we don’t even know how much it consumes our lives right now. And, I think once we leave, it’s only then that we’ll start to kind of unpack this.”

The Gilchrests are leaving Judson for a new life in a suburb of Washington, D.C. Leaders in Perry County are looking to bring some kind of hospital to fill the void. One option is a small operation called a Critical Access Hospital with an Emergency Room and no more than twenty five beds. Even if they succeed, Kendal and her family won’t be there to see it.