Many U.S. family physicians work in small rural community hospitals; they also lead health care teams in those facilities and interact closely with their hospital administrators. One such hospital executive is Tim Putnam, D.H.A., president and CEO of Margaret Mary Community Hospital in Batesville, Ind., and president of the National Rural Health Association.
Tim Putnam, D.H.A.
In mid-September, the NRHA held its annual Rural Health Clinic Conference and Critical Access Hospital Conference in Kansas City, Mo. Putnam opened the second conference with a presentation that highlighted the administrative challenges of providing rural health care. A few weeks later, Putnam shared his thoughts about rural health with AAFP News.
Before getting to any questions, Putnam noted that during his NRHA presidency, he's come to have great respect for the AAFP and its mission. "Family physicians are held in high regard throughout rural America, and many have worked with NRHA to help us achieve many of our goals," said Putnam. "There are some clear natural synergies and opportunities that the NRHA and the AAFP share, and those make us good partners in our mission to improve rural health."
Putnam then answered a series of questions posed by AAFP News.
Q. What is the hardest part of providing rural health care?
A. Overall it is very rewarding, but it is frustrating when I see patients leave our area for care we can provide and go someplace else with a great marketing campaign. Also, the challenge of rural health care providers staying financially viable has been difficult to watch. A rural hospital closes every three or four weeks in this country, and nearly 50% are running in the red every year. It's difficult to see dedicated people struggle to remain viable and continue to serve their community.
Q. What is the most rewarding component of your work?
A. The greatest benefit of working in rural health care is the opportunity to improve the lives of friends and neighbors. The ability to make an impact on people I care about and interact with regularly has rewards few other professions can match. To have someone come up to me at a basketball game or in the grocery store and tell me how the health care team had a positive impact on their life is priceless.
Q. How does a rural hospital gain the support of the families who live in the town and surrounding communities?
A. Trust is vital for any health care delivery system; rural hospitals that lose the trust of their community will struggle to survive. Everything you say must be presented with integrity, because if the hospital administration is not truthful on issues, then people begin to doubt their lab results and diagnoses provided at the hospital or clinic.
It's also important to acknowledge and respect local challenges. Be open to criticism and input from people who doubt that you are working in the best interest of the community. I've been in public meetings where people have spoken out against the hospital for a variety of reasons and later learned that most attendees were impressed I was there, remained professional and took the heat.
Q. How does an outsider step into a tight-knit rural community and gain its respect?
A. Integrating into the community is a rewarding part of being a rural health care leader. It's like becoming part of the family and you get to make a difference in the lives of people you really care about.
To do so, realize that your desk job is only part of the work; you must also understand the obstacles folks face. It's important to be seen in the community. Shop locally and enjoy events that are not health care-based; go to ballgames and farmers markets and local festivals. These activities allow for casual conversations that are an invaluable part of understanding a community.
You must also celebrate joys and mourn losses with your neighbors. You'll know you've become part of a community when you're invited to weddings and graduations -- and attend funerals.
Q. What can rural communities do to grow their own health care workers, and what's the timeline for success?
A. It's not like planting seed corn; rather, this is planting an orchard and it takes a decade or two to really be successful. For the last eight years, we have worked closely with our local Area Health Education Center and high schools to allow students to complete a formal mentorship program at our hospital and clinics. Dozens of students each year spend a significant portion of class time in various hospital departments, including the ER, obstetrics, physical therapy and surgery.
We are just now starting to hire the students who went through this program as juniors. We also have a strong pipeline of students in nursing, medical school, physical therapy and other health care fields. The work we've done over the last decade makes the future look bright in terms of our next generation of health care professionals.
Q. How can partnerships with schools, nursing homes, churches and others help create a better community health care system?
A. To improve our community's health, we work closely with organizations that are not directly involved in health care in order to pool our resources. We can use these organizations as force multipliers to collectively be more effective than anyone is alone. That said, it's important to recognize organizational leaders who are open to collaboration -- because not all are -- and do everything you can to build bridges with them.
Q. Why are rural community hospitals well positioned to excel in the field of population health?
A. I'm a big believer that rural providers are leaders in population health. The more defined the population is -- like what you find in a small town -- the greater the chance to address the social determinants of health and improve outcomes. The most successful population health models are those that invest in primary care, wellness and prevention; our rural health system is very focused on all three of those components. Primary care physicians lead this work, and they have a stronger voice in rural hospitals than in tertiary care centers.
Q. How can small rural hospitals tackle tough issues like addiction, behavioral health and mental illness?
A. First, we must realize that treating these conditions is our responsibility. If we limit our scope of care to pneumonia, congestive heart failure and other medical conditions without treating addictions and behavioral health, we will miss an opportunity to significantly improve the health of many of our patients.
Unfortunately, the resources available to effectively treat these conditions are rare in rural areas. It will take partnerships with local judicial systems, groups like Alcoholics Anonymous and tools like telepsychiatry -- all coordinated by primary care physicians -- to begin to gain control of these health issues.
Q. How can community hospitals and their leaders best learn from their peers?
A. Get out of your hospital and learn from the successes and failures of others. If you are struggling to solve an issue, chances are you have a colleague in a similar facility facing the same issue. Leaders must reach out to each other to find solutions or at least share frustrations and failures. Knowing what doesn't work is as important as knowing what does. In stark contrast to the hypercompetitive environment in urban areas, most rural leaders want to see their counterparts succeed and will be frank about their experiences.
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