Caring for Rural Communities: The Unique Design Needs of Critical Access Hospitals

If you live in an urban area, you may take for granted that you can call emergency services and have someone on the scene within minutes or hop in the car to reach a hospital before a bad situation gets worse. That’s not the case for the tens of millions of Americans who live more than an hour away from the nearest trauma care center. Fortunately, Critical Access Hospitals are there to step into the gap, there to keep care accessible and local, so long-distance transportation isn’t a barrier to care.

Hosted by: 
Matthew Gerstner - BWBR AV Production

Guests:
Brad Krump - BWBR Principal, Director
Scott Kirchner - BWBR Principal, Leader of Omaha Office

Music provided by Artlist.io
Siberian Summer by Sunny Fruit
DuDa by Ian Post

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Transcript

Matthew Gerstner  00:10

This is Sidee of Design from BWBR. A podcast discussing all aspects of design with knowledge leaders from every part of the industry.

Matthew Gerstner  00:19

Hi, thanks for joining us for another episode of Side of Design from BWBR. I'm Matt Gerstner, your host for this episode. On this episode, we'll be talking about some of the unique challenges and opportunities faced by critical access hospitals, which for those of you who might not know, are specially designated facilities that provide vital hospital services to rural populations who would otherwise be unable to access them. 

Matthew Gerstner  00:42

We're joined by two of BWBR's healthcare principals, director Brad Krump out of our St. Paul office, and Scott Kirchner, leader of our Omaha office, both have deep industry experience and passion for supporting the important work these facilities do for their communities. Brad, Scott, thank you both for being here today.

Brad Krump  01:00

Matt, it's a pleasure to be here.

Scott Kirchner  01:03

Yes, thank you, Matt.

Matthew Gerstner  01:05

For people who live in metropolitan areas, there's a lack of knowledge overall about health care out in a rural community, about what needs to happen out there. And I think to some of our listeners, understanding what makes critical access hospitals unique, would be a really good thing to understand. So what in your opinions, what makes critical access hospitals unique?

Brad Krump  01:29

There's a lot of things that make them unique, I think many smaller communities. They really want to remain independent, as a organization as long as they can. They feel that's a great way to serve their local community, and have local community involvement. When we talk a lot with in our visioning and talk about what community and organizational goals and needs are, most of the time we hear about the desire to remain independent, and how can they do that, and how important new facility may be to allow them to keep their independence. At the same time, they recognize that hopefully the cost will not become a barrier to remaining independent. And the reason for that is the high cost of construction and project costs at the moment. They've really done a number on project budgets.

Matthew Gerstner  02:22

That's a good point that was gonna be one of my next questions actually is, you know, just we're seeing escalation across the board, you know, for any any project type at this point. I'm sure it is impacting these smaller communities in a bigger way. So what are the benefits of remaining independent besides having that local community recognition, you know, as being part of that community? What are the benefits to them of staying independent,

Brad Krump  02:49

I think one of the big things of remaining independent is the ability to make decisions about their future. And not that being part of a system is bad. But the local control is sometimes removed,

Matthew Gerstner  03:03

I can see that being an important thing for having that identity. 

Scott Kirchner  03:06

Yeah, and you know, kind of tagging on to that, when you start looking at critical access hospital in the communities, they, they tend to also be the biggest employer in those communities. And so keeping those employment decisions and that type of stuff at the local level, is huge. You know, and a lot of times when we go in and start talking about efficiencies and different things like that, and staffing efficiencies, we have to be cognizant of the fact that you're not going to gain a bunch of efficiencies, because you also are employing a lot of the community, you know. And so there's a, there's a delicate balance there.

Brad Krump  03:45

Scott what's become really hard is when the local subway can pay an employee more than, you know, 15 bucks an hour to, to serve meals in the local community. And now, some of those other positions are then harder to fill. It's changed the operational costs, you know, increased the operational costs for the materials, the janitorial services, it causes an undue burden on how to pay for things. 

Matthew Gerstner  04:16

Right.

Scott Kirchner  04:17

Oh, without a doubt. And then, you know, like, you've kind of mentioned there, Brad, I mean, you know, hospitals, not just nursing staff or administration or surgeons, I mean, there's a whole support structure, you know, starting with EDS and facilities maintenance, and, and those folks, there are interval parts, you know, and to maintain them. I mean, you're, you have to start paying the market rate and you can work at the subway and not be on 24 hour call but lighter, ya know, and so there's there's definitely a difference between the two. You have to be willing to pay the freight for those. I guess.

Matthew Gerstner  04:55

I can see that being, definitely being a challenge. I mean, in the current economy, that's been worse. seeing that in numerous markets, obviously. So with the challenge in pay and attracting staff, I would assume that the quality or the level of the hospital itself, and some of these upgrades are kind of joined into that. It's not just the pay, but it's where they're working. And the the care that they're able to provide would kind of fall right in line with attracting staff wouldn't it?

Brad Krump  05:29

Matt, physician recruitment, and that is another challenge for smaller rural communities. It's not everyone's desire to be in a small local community. However, there is a niche for it. We have seen, you know, folks that are getting closer to retirement, those physicians want to move and enjoy some of the benefits of being in a small rural community. I think it's a little bit more challenging to find young providers willing to move out to a small community. So sometimes there's a premium that needs to be paid, or worse, you know, the larger regional locations can pay more, you know, the larger systems can pay more. So now you find the critical access hospitals, having to pay more for their providers just to be able to recruit to a smaller community. So some of the things they need to be able to do is help offset that find the right people that want to be in that community, that have the same goals and desires to be in a smaller community. It's definitely a challenge for organizations,

Matthew Gerstner  06:37

It sounds a bit like an aligning of all the right you know, all the right pieces, trying to get all those things aligned, it's you're talking about pay, we're talking about the level of care that's being able to be offered, we're talking about people's desires, and where they want to live and where they want to be. It sounds like a very unique challenge, in a lot of ways. When we first started talking before we set up this recording, we were kind of talking about three types of critical access hospitals. And can you explain to our listeners, kind of what those three types are?

Brad Krump  07:12

There's the small, rural, independent health facilities, there's the 10 bed critical access with clinic, they have their own sets of design needs, and and how do we provide flexibility, adaptability for them? To right size it. And then you have the large critical access, which could be independent or part of a system? And, you know, they're trying to figure out how to, because they have high average daily census, they're looking at how do they become stronger in primary and specialty care? Which then, you know, drives, surgery cases, etc. To provide more revenue, which then helps offset some of their other costs. For example, behavioral health, if they have a behavioral health component? Oh, yeah. favor, I'll typically loses money every year. So, you know.

Matthew Gerstner  08:05

How do you offset those costs, yeah.

Brad Krump  08:07

The additional revenue and the surgery helps pay for some of the other things that that is an unprofitable service line,

Matthew Gerstner  08:15

Yet, it's so important for those for those communities.

Brad Krump  08:18

Scott, what do you see down in your neck of the woods? Do you see it differently in regards to, you know, do you see it as three different types?

Scott Kirchner  08:27

Yeah, I would agree with that. The way I kind of look at them, Brad is you have your your ones that are truly out there. And you know, they're a distance away from any metropolitan type hospital. So really, they're the ones that are going to, you know, say there's a car accident or something like that. They're the ones that are going to bring the folks in, stabilize, and then move them out, right, to more of a trauma type, situation or hospital. And then you've got what we have a lot around here, you know, the Omaha, Lincoln, metro areas, we have a lot of bedroom type communities that will have those critical access hospitals that are just 25 beds, you know because I don't need all the beds, but they have a lot of the ancillary services, surgery services and stuff like that they, you know, there's a critical access hospital around Lincoln that has 25 bed, but it's got six or seven OR's,right? But it's a bedroom community to Lincoln, and you can get a lot of those services for those folks without having to go into Lincoln or Omaha, you know, and then you have some that are just scraping by. They're barely making it, you know, just from the fact that where there at a location. So you know, what makes a critical access hospital unique, I'd say, one, it's the type of services that they're fulfilling and their locations really dictate, you know, how they operate. Cuz some of those folks are, they're working as a MASH unit almost, in some cases, you know what I mean that we're out on the frontlines and the conflicts and stuff. So collect stabilize, move on.

Brad Krump  10:19

Scott, you are correct about how veteran communities are similar to Lowe's, you know, kind of communities of 10, 15, 20,000 people, that they have a strong inpatient census. And then people want to be, want to get their care close to home, they don't want to have to go down to the, you know, down to the Twin Cities or down to Lincoln, or Omaha, or, you know, in Idaho, they don't want to go to to Boise they want to be, you know, have their care somewhere close to home.

Scott Kirchner  10:51

Yep. Family Access is important to all that, for sure.

Matthew Gerstner  10:55

So we're talking about family access care, we're talking about a smaller communities and really a desire for the people that live there to stay within their own community to have their health needs met. Can you talk a little bit about rural emergency hospital conversions and how those decisions are playing out for the clients and the communities?

Brad Krump  11:19

You know, rural emergency hospital conversions is relatively new, that legislation did not pass till 2021. I think for the very small communities that have a low average daily census, that is something that they may want to consider, especially if they're independent. I think the challenge to it, where it may be difficult, is where are you going to transfer the patients to? And I think there's this discussion between independence, profitability, viability and while the rarely emergency hospital conversion will give you more dollars reimbursement from Medicaid, Medicare, or CMS, how does that help the community? And so I think there's going to be a struggle between the conversion to a rural emergency hospital.

Scott Kirchner  12:11

In some cases, the rural emergency hospital came about as a, I'm not gonna say it's an answer to but you know, CMS has a lot of rules and regulations when it comes to critical access status. And then in a situation that I've currently worked with a client, they are 34.6 miles and 34.4 miles away from other critical access hospitals. And if they wanted to do this, a greenfield facility, they couldn't do it, because of the CMS regulations that you have to be over 35 miles away from an adjacent critical access hospital. So that becomes a rub point for this hospital to be able to do any work. I mean, they're in a situation where they've got a facility that's built back in the 50s, that needs renovation, or more than likely needs complete replacement, just because it's been run to the end of life, but they can't do it. So the rural emergency hospital would allow them to do that, and move to a more prime location to help serve the community. But they have to give up their inpatient beds. So that's the flip. That's what they have to decide whether or not that's what's important to them. In some ways, it's helped, but in some ways, it still is, they're having to cut off some of their income in order to be able to do it. And that's because of the rules that are behind, or the regs, regulations that are behind, you know, what constitutes a critical access hospital.

Brad Krump  13:51

I think there's a lot of digging into an REH. And understand what are the benefits and what are the inconveniences of converting? 

Scott Kirchner  14:02

Yeah.

Matthew Gerstner  14:03

So we're talking about the critical access hospitals, we're talking about emergency departments, inpatient beds. And there's a whole other aspect of healthcare that we haven't mentioned yet, and that's behavioral health. And that presents its own set of concerns and reaching rural populations and maintaining profitability. Can you talk a little bit about some of the factors that play with behavioral health in these environments?

Brad Krump  14:30

Now, maybe we start first with critical access hospitals can have up to 10 behavioral patterns that is a maximum that they could have as an organization. With that said, there are not many that offer behavioral health services because of the reimbursement model that's created. For those that do have it. It's a benefit because it helps free up emergency room beds. So there's the positive the negative for the ones that do have it is they typically lose money every year servicing those patients because of the lack of reimbursement.

Scott Kirchner  15:03

Well, I think it all kind of tagged on to some of the behavioral health, we have a drug abuse, or just there's a drug problem in any and all places. It's not just in the cities, it's in the rural communities, you know. And when some of those folks present at an ED, there's no place for them to go. And so, you know, we've had, you know, in meetings lately, where owners will tell us that a patient has presented, they've had to keep them in their ED. So they're basically tying that one room up for days on end, right? It can be up to three days, it can be up to five days for that person to be in that ED, that exam room. And that's not a patient room. So that means that room doesn't have to have windows that doesn't have to have toilet and shower attached. So we have to think about the way that we're treating folks that are presenting and need to be given health care in a humane way. And I just can't imagine somebody being in an exam room for three plus days.

Brad Krump  16:16

You have Scott to the other challenge with that is, how do you keep the staff safe? Correct, because when some patients arrive, they are not aware of their surroundings. And so we're trying to balance the humanity of the patient with the physical conditions of the room to make for a safe place. 

Matthew Gerstner  16:37

And it seems like we're also talking about communities that may not have this available, in a lot of cases, where it's, from what you were saying it's it's not a service that's necessarily offered in all communities. In those situations, what are you seeing them doing, where they're getting patients in, that are behaving this way, or are having these issues?

Scott Kirchner  17:01

Well, if you don't have a room that set up to handle a behavioral then you have to have one on one. And that means a staff person has to be with that patient 24/7. And that means basically, you've dedicated one, ED staff to that room. And if you have other staffing shortages or, you know, say you're on third shift, and you only usually have two nursing staff, well, you're gonna have to call another one in because you've got one dedicated to that behavioral patient. So there's a lot of things that happen and snowball as that goes as that patient is in that facility.

Brad Krump  17:44

In planning discussions, we need to understand how many behavioral patients that we need to plan for, which usually is a plus to what we would normally provide for emergency patient rooms. And because they're being held for such a length of time, as Scott mentioned, you know, three to five days, they need to be in a safe place, staff need to be safe from them as well. And yet, the rest of the ED needs to keep taking care of the rest of the community needs.

Matthew Gerstner  18:20

I can see that being a big challenge. Are we are we seeing changes in, even small changes, in the design them to as we're talking with clients about the potential for are these behavioral, you know, issues coming in? Are we seeing changes in how we're planning and how we're designing for those.

Brad Krump  18:38

I think Matt, we're definitely doing behavioral safe rooms that are dedicated to behavioral health. And we're starting to talk about, is there a potential for doing an Empath type unit, where we're trying to put it on an exterior wall, give them access to daylight, give them softer space to try to minimize how they're feeling within a space and make it feel safe for them. So we don't have to treat with meds and they can feel more safe in an environment.

Matthew Gerstner  19:11

That sounds like just a wonderful way to go about it, if at all possible for these hospitals. So we've talked about a lot of different aspects in regards to critical access hospitals and the potential for rural emergency hospitals, and it sounds like there are a lot of things to try and consider here as they're potentially talking about renovations, additions, even building new and it sounds like there's a lot of challenges that they're facing. 

Scott Kirchner  19:41

Thought about. 

Matthew Gerstner  19:42

Is there anything that we haven't talked about in regards to critical access hospitals that either one of you would like to just kind of mention?

Scott Kirchner  19:49

I think that's for the next episode. It honestly, Matt, Brad and I could probably look at tell you two stories and probably stories are the best way you know, for us to impart some of that knowledge over our vast experience of working in these critical access hospital realms. I mean, I love working in these facilities, because generally the people that are working in these facilities are doing it for the right reasons. And they are giving back to their communities that are, they're just good people. They're true people. And that's what I've always enjoyed about working in these facilities and trying to help them up their game in the care that they provide.

Brad Krump  20:33

Like Scott, growing up in a small rural community, part of my heart is near and dear to serving small communities, I think, you know, right sizing facilities, how to provide flexible, adaptable spaces and planning ideas, how to create innovative planning solutions to help support the organization's operations. You know, there's so many different things to assist them to make things better for the community. My goal is how to be a trusted strategic advisor based on team's experience in the critical access health, and the critical access hospital environment, in the rural health clinic environment, and from a funding standpoint, USDA. How can we assist in getting them to better financing for the long term of an organization which USDA does a great job.

Matthew Gerstner  21:29

And that sounds like a whole nother episode diving into USDA and funding and, and how they're actually able to turn profit when maybe they have departments that don't. Well, I can't thank you both enough for your time today. This has been a wonderful conversation, kind of that high level view of critical access and the struggles that they're facing the challenges and a lot of the good work that they're actually doing, and just different ways that we can go about helping them. So thank you both today. Really appreciate it.

Brad Krump  22:01

Thanks, Matt.

Scott Kirchner  22:02

Thank you , Matt

Matthew Gerstner  22:03

And thank you to our listeners for joining us on this episode, and we'll see you on the other side. 

Matthew Gerstner  22:09

This has been Side of Design from BWBR. Brought to you without any paid advertisements or commercials. If you found value in what you've heard today, give us a like, leave us a comment, or better yet, share us with your network. You can also reach out to us if you'd like to share an idea for a show or start a discussion. Email us at sideofdesig