Rural Doesn’t Mean Simple, with Dr. Robert Moser (part 2), episode 12

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Rural Doesn't Mean Simple, with Dr. Robert Moser (part 2), episode 12

Join us for the latest episode of Health on the Plains - a Kansas Health Institute podcast focused on rural health challenges and opportunities in Kansas. Meet the leaders and doers working to make communities healthier, more vibrant places to call home.

Summary:

OnHealth on the Plains, episode 12, host Wyatt Beckman continues his conversation in part two, with Robert Moser, M.D. They discuss the potential for telemedicine in rural health care, particularly for solo practice providers. They discuss the importance of maternal health care in rural communities within the High Plains region and highlight anupcoming symposiumfocusedon rural maternal health. They talk about the unique challenges of maintainingobstetrics skills among rural health professionals. The conversation also touches on the unique challenges of health care provider recruitment and retention in rural communities.

This episode is part 2 of the conversation with Dr. Robert Moser. You may listen to part 1 in episode 11.

Episode Highlights:

0:42 - 1:27 Host Wyatt Beckman introduces the episode, part two of his conversation with Dr. Robert Moser

2:00 - 10:27 Dr. Moser discusses the implementation of telehealth, highlighting its role in supporting solo practice providers, with Wyatt describing rural mindsets

10:40 - 23:30 Wyatt and Dr. Moser discuss the Kansas Center for Rural Health's second maternal health symposium and the challenges rural areas face in maternal health

23:50 - 28:00 Dr. Moser and Wyatt discuss retention of health careprofessionals in rural settings, and how it is a community-wide effort

28:05 - 32:48 Dr. Moser shares his hopes for the future impact of the Kansas Center for Rural Health

Transcript:

Voice over 0:00
This is Health on the Plains, a podcast about rural communities, rural life, and the many factors influencing the health and well-being of rural Kansans. Health on the Plains is a podcast from the Kansas Health Institute, a nonprofit, nonpartisan, educational organization committed to informing policy and improving health in Kansas, through honest, nuanced conversations with leaders and doers from a variety of backgrounds. The Health on the Plains podcast offers unique insights into rural health challenges in Kansas and shines a light on the people and organizations working to make their communities healthier, more vibrant places to call home.

Wyatt Beckman 0:42
Welcome back to another episode of Health on the Plains. In this episode, we have part two of my conversation with Dr. Robert Moser. We're talking about the Center for Rural Health. In the rest of our conversation, we talk about telehealth and remote patient monitoring. We talk about attracting and retaining healthcare professionals in rural communities, and we continue to touch on maternal health and the challenges and opportunities that our rural communities face in ensuring and maintaining that healthcare access. It's a really good rest of our conversation, if you missed part one that's in the previous episode. I invite you to listen to that and then come back to this conversation, which is part two of my discussion with Dr. Robert Moser. Enjoy.

Something that I hear that comes up when we talk about solo practice or small communities and healthcare providers sort of being on their own, is the potential of telemedicine, remote health, and you touched on that from the education side, and what, what opportunities that's given. And I've heard it come up a couple times when we're talking about the Care Collaborative, but maybe, maybe go down that, that path a little further, what, what's the, what's the potential for telehealth, and what are some of the limitations for it to support those solo practice providers?

Dr. Robert Moser 2:06
Yeah, no, that is an area of interest in the Care Collaborative, you know, has looked at at some of that and implemented some of those models. So when we first began as a heart and stroke collaborative, one of the things we did in the 11 critical access hospitals we started with, we made available because we had the funding from that grant to pay for the subscription to put telemedicine into their ER, and so they could hit the red button and be connected and have a emergency room physician and critical care nurse right there who knew what their layout of their ED was, their hospital services, and they could help support either the nursing staff and/or the providers in managing a patient. And so a lot of great stories of hey, we had this arrived. Doc wasn't readily available. But nurse was and they assisted on helping to intubate the patient, because they had the right equipment and could guide them over the telemedicine so, you know, a number of the administrators and providers in our rural communities where we had that installed, you know, talked about, this is a great retention tool. It's a great recruitment tool, because it does show that, you know, yeah, you might be the only one physically present, but if we set this up right, you've got supports, somebody, you know, that has the experience of talking somebody through managing a patient or a procedure or something remotely. And so, you know, a couple of sites have dropped it because they've actually got, now more providers, and in some cases, providers with, you know, different specialties they didn't have before we started. But there's several that still have that, and others that learn from them and have expanded to that subscription service. So I definitely feel like, you know, telemedicine has a huge role as we look at the challenges of providing healthcare access. And particular, you know, it sounds simple, you know, well, gee, you just need somebody that has a little bit of medical knowledge and they can manage, you know, chronic conditions and number of things. But you know, illness knows no place and time, you know. And so you never know when it's the trauma, you know, the kid choking on something. So you need a lot of different skills, and skills you may not use very often. So how do we keep those skills? Telemedicine and on-site training, I think is going to play an important role in that. The telemedicine can help with developing a simulation that they manage, you know, with simulators in the local rural facility. So I think there's a huge role for that, even with EMS, another area; you talked about your mother being head of EMS in Ness County, we have a huge challenge in getting local citizens who will take the time and effort, the training, to become local EMTs. And oftentimes, you know that's at the best, you hope you have basic life support EMS. You really need advanced life support. Because, you know, for example, once you give the clot busting drug to the stroke or to the heart patient, you really need advanced life support in transferring the patient, if you don't have that by ground, you know, for, you know, the 30-60 mile jaunt, you definitely need to have air medical available, which adds to the cost, you know, of services our rural patients get. But you know, the military's looked at putting telemedicine in the back of, you know, where the medics have somebody, you know, stations and support them. And so, I think you know that's something that we need to be looking at too. But that's where you know it's one thing to have, you know, the fiber optic cable brought into your emergency room, and to have good connection for that. But you could imagine how challenging it would be to have a telemedicine support for ambulance services are going all across our highways. And I've traveled Kansas enough, you know, putting on about 30,000 miles a year, going, you know, to these trainings and working with our rural communities, that I can tell you there's still a large number of spots that cellular coverage is pretty iffy.

Wyatt Beckman 6:18
Yeah, the yeah, it's a it's a different challenge. But the, I think that it sounds like, and I think you've, you've seen evidence of this where, you know, there's, there's a lot of potential, and we're seeing successes where telehealth and remote monitoring and some of these types of approaches can help fill some gaps and provide support. What it, what it can't do, is it can't replace that we still need those, those healthcare professionals and providers in those communities. And it's a way to support them, and when they encounter something that they've never seen before, or that they just need some support, it can it can help there, but it doesn't. Unfortunately, we still have the challenge of, we need well trained, supported professionals in these communities.

Dr. Robert Moser 7:13
Well and I think the key is, is, as I mentioned a little earlier, you know, is sometimes I think when you bring up just the word rural, you know, people think simple, you know, it's not complex, and so they kind of sign off. And some of our academic training programs, I think, have the wrong mindset. You know that, that there's some equivalency, you know, between training, but you know, there's, as mentioned by, you know, Sir William Osler that you know "the disease doesn't read the textbook," so it doesn't necessarily know how it's supposed to present. The only way you really appreciate the variances and the challenges and identify where you're strong and where you're weak in your skill set for managing you know patients when you're it, is to have enough clinical exposure. And that means, you know, emergency room, obstetrics, you name it, pediatrics, because, again, you know when it happens out there, you're you're likely going to be it. So whether it's nursing, whether it's, you know physicians, the physician associate, advanced practice nurse, whatever it may be, I think it's critical, you know before you go out and you're covering the ED in a rural community, or you're the hospitalist, or you're the clinician, you need to have a broad experience, a deep experience. Otherwise, again, our downfall in rural health is that if we can't provide that service local, then the patient has to load up and go somewhere else, and it's not appreciated the cost out-of-pocket to our rural citizens compared to urban settings, you know, of what it takes to get to that higher level of care. And so telemedicine, hopefully, you know, will be another way for the follow-up in chronic care management for some of those to reduce that cost, but, but it's always kind of been something. So I look at studies, I kind of always, Well, why didn't they look at how much it was actually costing the patient? Loss of time from work, you know, the gotta find childcare, I've got to travel 60 miles, you know, one way, that's not always reflected in in some of the studies and so, but that's just rural health in general.

Wyatt Beckman 9:25
Yeah and we, you know, we, being people that grow up in towns like that, can become sort of normal. We can normalize that, but that, no, well, just, you know, it's an hour away, so we just gotta, just get used to it. But it doesn't have to be that way, if we can find ways to innovate and be creative and fill some of those, those gaps. The, I- I love, the the point you made, and we've, in some of my conversations with other folks, we've really talked about this, that that misconception that rural means simple. And that it, maybe there are some things that are simplified, relative, or there are fewer options of certain things, but but smaller doesn't mean less nuanced or less complex things. In a lot of ways, the people that are doing the work in those places have to have a broader range of skill sets and more flexibility to cover even more ground, because there's not someone to turn to to fill that gap. And one of the challenges, I think, is especially important, and I know that your center has been doing work on, and is especially nuanced, even in those rural communities, is those maternity deserts: access to OB care. I know that the center has a symposium coming up soon, and that some of your colleagues are involved in work there. I know that for folks in our rural communities, that's a very pronounced concern where thinking about recruiting people into to a community, when you can't provide OB care and you want to start a family, that feels like a big, big gap. Tell me about some of the work the center's doing, uh, try and ways you're approaching this really complex and really important challenge of access to OB care and maternal care?

Dr. Robert Moser 11:24
Sure, yeah, no, we're fortunate at the center, our Associate Director for Research is Dr. Karen Weiss. And Karen had a career in the military, but a lot of maternal health and military, most people maybe don't appreciate, but it's also an environment is often remote and under resourced, and so she brings in some great perspective. She was a Salina native and such. And then Dr. Lynn Fisher, who's our Associate Director for Service and Education, grew up in western Kansas and practiced in Rooks County for a number of years, is now the Director of Rural Health and Education in the Wichita Department for Family Community Medicine. So we all have a passion about providing services and recognize that the number of areas that are delivering has continued to dwindle and and some of the other challenges is, you know, babies don't know whether the local hospital delivers or not. So when they want to show up, they're going to show up. And so for sites, the longer they go without having had a delivery. You know, everyone's losing some of those skills of, how do I assess a laboring patient? How do I manage a precipitous delivery, etc and whatnot. So, so we need to address, you know, how do we keep some skill sets up? Because these kids are, you know, and I can tell you anecdotally, anecdotally, visiting with a couple of sites when I've been out doing trainings on some of our time critical diagnoses, I always like to ask, you know, how are you developing your local workforce pipeline, and what other challenges have you seen? And have asked more specifically about, hey, have you guys had to deliver any babies unexpectedly, you know? And one county said, yeah, we had six last year, and we haven't delivered babies here in like, six years, you know. And I said, well, that was probably pretty exciting. It's like, yeah, we'd really like not to have any. Well, it'd be great. But how about you know, what are you doing to keep your skill sets up and whatnot? And actually, they decided they need to have, you know, kind of like a skills fair where they can develop those trainings and keep those skills set. So, so our symposium that we had for the first time last year was really great in a lot of information and feedback from you know, providers as well as small hospital administrators about what are their challenges. And, and they face, you know that, gosh, if you're doing, you know, a low number, which by low number, I guess it depends on your perspective. You know, what does it take to keep your skill set up? And I don't want to make it sound like, you know, once you learn how to ride a bike, you know, you can always ride a bike, but that OB is similar to that, but you certainly do start to appreciate, you know, hey, this is, you know, the feeling that this is going well, or this isn't quite right, you know that you need to pay more attention to it. So what is that magic number? And I'll leave that, I think, to each provider, each facility. I don't necessarily like to put a number to that, but whatever that number is, you you've got to look at that. Well, is that going to be a cost leader for the health system locally? You know, we're not going to make money on this, but we're going to provide that because we recognize it could be an economic development issue, that we're not going to recruit young people to our community if you don't have health services that provide for what they need. And so, you know, even if you have a good relationship with a nearby county that is delivering, once you deliver, and if that's a family physician, you're going to be going back, probably for well child visits. And eventually, you know, healthcare goes where mom goes. And so, you know, could care, collaborative prenatal care model, be something to look at, where you do your first trimester, maybe at home, and then you develop that relationship with a provider who's going to deliver. Well, some of that has to depend on what's a skill set for that person that's doing the prenatal care. You, you know that medicine is really about relationships. The better the relationship, the better the communication, the better you know, when things aren't going well, work out and whatnot. So some providers that are delivering are not keen on the idea of a collaborative prenatal practice, because they want to establish that relationship as early as possible throughout the whole pregnancy. And I can appreciate that, having delivered babies and whatnot, including some that travel more than 60 miles to come to me. But we have a good opportunity, I think, to look at, how can we train up and keep those communities that don't deliver anymore, keep their skills up so that maybe the opportunity for doing a collaborative prenatal care model might work. But that's going to be challenging, you know, because you've got to get a comfort level for the delivering provider to accept that, as well as keep the training level up for the staff and the providers in that local community. So you know that you also have to have reasonable reimbursement for a rural community practice, and not all of you know our third-party payers, not even Medicaid, models their reimbursement rates to fit the way the feds have with the cost-based reimbursement for critical access hospitals. So, you know, it's recognized they're low volume, but if you've got to have everything available to take care of certain issues, then the insurance reimbursement needs to reflect that. And I don't care who the payer is. And so yes, it will be higher costs, but it shifts that higher cost away from the patient's pocket, back to somebody you know, who's actually supposed to be there, created for covering the cost of access. So, so I think we're going to have some great conversations in the second symposium. We're going to actually, Dr. Karen Weis and the staff at the center have been working on mapping where deliveries are occurring, as well as where prenatal care services are available. The March of Dimes has a map on their website, but we found it wasn't in like a lot of healthcare data, it's tough to keep it up to date, but even the original map that we were presenting last year from the Kansas Hospital Association. There are two more counties that have quit delivering, you know, so it unfortunately, you know, looks, when you look at the map, the highway 81 it goes north and south out of Salina; west of that, those spaces are getting larger, you have, where there's no OB services.

Wyatt Beckman 17:58
Yeah, and we're particularly focused on, on Kansas, but that that, that dividing line, we see it stretch into Nebraska-

Dr. Robert Moser 18:09
Yes.

Wyatt Beckman 18:09
- down into Oklahoma and eastern Colorado. That High Plains region is where we're seeing a lot of those, those particular challenges. It, I think the, and I know that it's a nuanced topic and nuanced challenge, and I think from sort of the outsider perspective, that angle of, how do we keep our professionals skills where they need to be to where they can be confident in keeping providing that service? That's an angle of this that I think a lot of folks probably- that's not very top of mind, but that's crucial to them- to having good outcomes, where professionals are well prepared, but it's also part of how, how do we make the business side of this work with the local challenges and opportunities and work with the relationship side of this. There's so many moving pieces to keep a service available, particularly in a place that we're seeing the number of births go down, and that intersects with some of the broad changes we're seeing that are outside of a lot of our control. Of a lot of communities, populations are not growing. There are some that are, but a lot of them are getting smaller. And so it becomes really complex, and it sounds like with the center, you're in a position which you can lean into some of that complexity and have conversations about these different pieces with your different partners, and what a great resource for our state to have folks like you all that have the experience to draw on, where you've been there and faced in a lot of ways, but then can also zoom out to 30,000 feet, and say, "where does this intersect with policy? Where does it intersect with training and research?"

Dr. Robert Moser 20:05
Yeah, yeah, absolutely no. It, it's come up a lot. You know, a dirty word in rural is consolidation. It wasn't very popular when they decided to do that for the school systems. But needed, you know, to support numerous ones for the same county. But, would consolidation, you know, work the regionalization and that might, but it doesn't address all the issues. You know, because even if you look out across the state and look at the number of OB/GYNs, the obstetrician gynecologist that are in practice, in what would typically be the referral, you know, the receiving facility, for some of those patients, those numbers are declining, and their capacity is getting to a point where, you know. Gosh, and I suspect, you know, if you're an OB/GYN and you know, going in, yes, I'm going to be likely taking call, being on 24/7, delivering babies, and disrupting my life and work balance. But, if all of a sudden you lose your partner, and you're one of three, and now you think, oh gosh, my workload is going up a third, it may be unattractive enough that now they're ready to step out and go find a practice with larger number where they don't have to be on call as much. And now, all of a sudden, now you don't, not only not even have, you know, the family medicine OB provider, you don't have the OB/GYN backup in a region. But regionalization may be an active response team. You know that, hey, if there is truly a trouble delivery or something that can be put together, and it may not, you know, be feasible until you get an adequate number of providers, because I could imagine, you know, what it's like to be called out of a busy clinic and having to go manage something that wasn't necessarily yours to begin with, but you're the expert, you know, so you're going to get called in. So, yeah, we've got to look at it, because keeping those skills up will be one thing, and simulation isn't the answer for it all, because you really need the immersion. So our nursing staff who are going to be managing the laboring patient and the surgical scrub nurse who's going to be helping with the C-section, you know, if they need certain skill refreshers, you know, they need to go to a place where they're going to get enough of that in a short amount of time. But meanwhile, they're stepping out of the workforce for the rural hospital. And who, who pays for replacing that, you know? And how do you pick the right time to go do that, and what do you- where do you stay? You know, so it's just an added cost in order to provide the service. And I think it's where it's just easier, you know, as reimbursements gone down and the interest of both provider and support staff in in providing labor and delivery and obstetrical services gone down, it's understandable why this is, you know, occurring.

Wyatt Beckman 23:02
Yeah, and it, it probably goes without saying, but it's maybe, I'll still say that I I imagine that most of the, if not all of the, the healthcare organizations or a specific hospital, they would like to keep these services if possible. It's like a lot of cases. They're living in these communities too. They want those services to be provided. But there's all these forces that are working against it, and there's, there's trade offs to keep other services available. And it becomes really complex. And the the other piece that you mentioned that is an, an important ingredient in this, that connects with the whole community too, is it's one thing to get a professional there, a provider, a nurse, a physician. It's another to keep them there. And part of keeping them there is, is how their, their position is set up. Do they have the ability to have a break when they need to, do they have that work life balance? Can they take advantage of some of the great things about living in a rural community? And if we don't get that right, then we pay for it on the back end, where we have a physician come. They're there for a couple years, and then we start over again. And, and I know that's a concern, a challenge that that I hear a lot, too, and, and it's that next step. It's, it's not. Like we need doctors and we need to keep them, which is a second layer to that challenge.

Dr. Robert Moser 24:40
Absolutely. No. That was something once I was fortunate enough to recruit my first partner through the National Service Corps, and he was attending the residency in Salina, and we'd been working with a community recruitment committee for about a year, I think, and they were kind of getting frustrated because they weren't having any success. They thought, you know, going out and finding a doctor, you know, to support our system would be no biggie. Maybe they weren't that unrealistic, but I think they were a little saddened that it hadn't happened. A good candidate hadn't shown up. So we were fortunate to get Dr. Ellis, Wendel Ellis to come out to visit the site. He brought his wife, young child and newborn, you know, on a cold, blustery January 5th of 1992 and we thought, gosh, he's going to come out here and see it's all gray and brown and whatnot. But fortunate, you know, that he was excited about, you know, the type of practice and we could do every, and anything we were trained to do, great support staff at that time, although it was growing and developing, and said, hey, I'm coming, you know, a couple of days later, which we were quite fortunate. You know, he grew up in Michigan with the small college, but did his medical school in Miami. And so I'm thinking, well, you know, if I can just get him out here for three years, he might stay, but it'll give us time to recruit somebody who you might think would be more likely to stay long term, right? Well, Dr. Wendel Ellis is a hard working, great clinician, and he's still practicing in Tribune, and was a big part of why we were able to build a rural, regional medical system. But we always, as we brought on new partners, we wanted them to get engaged in the community, whether it's inviting them out to the bowling league or the golf course, or whatever it might be, but to make sure that, hey, one more now makes you, you know, in a situation where you've got a little bit more opportunity for that work-life balance, and recognizing, yeah, you're one car accident away from being immediately critically underserved agrin- again. You know, so we kind of got in the mindset, you never stop recruiting to rural because, you know, it on average, takes up to three years to find a provider, and when you get them, you have to be thinking everything that needs to be thought of in retention. So does the spouse need a job? Do they, you know what, what's their experience in rural, and what do they like to do, and who else in the community? So to get them integrated is important, but you can't smother them, because they're adapting to, you know, a new life and new career and and whatnot, but you need to be there to support them, because retention, yeah, if you if you miss out on that, and you get in that revolving door, there are some communities that have suffered through that. And you lose a provider, and then you lose another one, two or three years later, the community, you know, when you lose them, they start going somewhere else because they need to get care, and they won't come back until that provider has been there probably at least three years. They have to prove that they're going to stick around before they move back into the local healthcare system. So you're right, retention is huge.

Wyatt Beckman 28:04
Yeah, and I really appreciate that story, and it's a perfect example of how the same, the same topic, physician recruitment, can look so different if we go in urban context first, especially our really rural context, where it's a community wide effort, and it's a community wide celebration when when a physician comes, and it's a community wide sort of morning, when one one leaves. We, I grew up in Ness, and we had a fantastic physician who was there for decades, and he finally retired and moved to be closer to some of his family, and it was a huge loss, and everyone felt it because he was- he meant so much, not just as a provider, but as a community member. And so that makes sense of, you know, it's, it's constant work, and you can't, you can't take for granted that once you've got them, that they're going to stay but the reward can be immense when you do find that great fit and you have a position that can develop those relationships and be there for the long haul.

Dr. Robert Moser 29:09
Yeah.

Wyatt Beckman 29:10
I- I've really enjoyed, enjoyed our conversation, and I, we've touched on a lot of- a lot of different things. And I want to end by sort of going back to where we started. We talked about the very beginning. You won recently this lifetime achievement award, and deservedly so, but that was a personal award for your work in collaboration with all your partners along the way. The center is just getting going, in a lot of ways. It's only, only a couple years old. If we think about that idea of a lifetime achievement award and we apply it to the center, if we, if we would fast forward several decades from now, what do you hope we can say are some of the lifetime achievements of the Center for Rural Health?

Dr. Robert Moser 30:02
Yeah, that can be, you know, from fairly simple to very complex. You know, but I hope it becomes an integral part of you know, both the thought process and the engagement process of folks who are looking at, you know, any initiative. Whether that is obviously healthcare related, so that the center can be involved in looking at, you know, does this make sense? Is, what's the impact going to be, and how's this supply into that rural setting? So we can be a great partner in that. I don't see that being our sole, you know, ownership, you know, and responsibility. So I think there's a number of opportunities, but when we do identify, you know, an issue, for example, I've got a one of our third year medical students and a PhD in clinical lab science, Dr. Nunez, who's working with me on a paper about a workforce study we did of the rural laboratories. Knowing that that's a challenge, but one of the things that we discovered is we have about ten counties where, plus, you know, ten that don't have a hospital, that don't have blood banking. So when you have a trauma and you need blood right away, how's that managed? So as a center tied into an academic medical center, where we've got, you know, transfusion specialists, we've got trauma surgeons, and we've got Dr. Karen Weis and her connection to the part-, Department of Defense, and I know they have to address this issue in their world. So what's, what's the best model for Kansas, you know? So I think our role is we'll have a number of success stories where we've identified issues like that. We've worked with the subject matter experts and others, other stakeholders. We've identified maybe the best practice, and because it's something that maybe hasn't really been studied, there may not be this evidence-based guideline out there to just follow and adapt, but something we have to create for Kansas to make it work for our communities, our local healthcare systems, our region. So I think if we look back at it, you know, in ten years, and say, man, they were really engaged in a number of these initiatives. They maybe didn't write the paper, they maybe didn't come up with the best idea, but they were part of connecting those who needed to be, you know, at the table, and working on some of those solutions.

Wyatt Beckman 32:27
And I think, I think, everything I've heard you, the team you've assembled and your leadership is taking the center down that path where we can look back and say that it played a big role. And I think the state is fortunate to have, that KU and partners invested in the center and you're able to do this work. I just want to say thanks again for taking the time to stop by. I know you're on your way to more work, and thanks for stopping by close to some of your old stomping grounds when you're here at KDHE, and we really appreciate the conversation, and thanks again.

Dr. Robert Moser 33:06
You're welcome. Glad to have been part of this.

Voice over 33:10
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