Critical care

It’s what these small hospitals provide the economies of remote, rural counties.
By Edward Martin
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Muffled voices and footsteps mark the Monday morning trail of a half-dozen hospital staff working their way down a hallway, stopping at one room after another. At the cluster’s center is Phillip Harris, a graying doctor in blue oxford-cloth shirt and khakis. He pauses at an open door to study the chart in his right hand. “She came in last night?” A nurse nods. “That’s right, late.”


A figure appears, teetering on a cane and steadied by another nurse. “I was woozy,” she says weakly. Harris sizes her up: barely 5 feet tall and frail as a whisper, her snowy hair still permed for church. She wears a floral-print blouse and creased slacks, the kind of outfit elderly country women keep in their closets — “just in case,” as they say. “We’re going to try to help you with that,” he says softly. Members of the group introduce themselves. “I’m James, the respiratory therapist. If you have trouble breathing …” “I’m Betty, and I’m going to be your nurse …” Melissa comes last. “I’m going to help you when you go home …” The possibility she won’t is left unspoken. Outside the window stand Three Rivers Health and Rehabilitation, a nursing home, and Windsor House, for those with dementia and Alzheimer’s disease.

The mood is brighter in another room. “You’re going home today?” The patient, bedridden but freshly made up, smiles and nods. “When you came in, you had too much fluid,” Harris tells her. “We’ve gotten rid of that. Your heart’s beating fine.” Helen Bernice Whitley, 83, stirs under the sheets. A retired bookkeeper and office manager, she has congestive heart failure. Daughter Jacquelin Nicholson is at her bedside. “A real blessing,” her mother calls her.

Then, that quickly, it’s over. Rounds finished in 25 minutes, the group disbands. Harris, a family practitioner who is Vidant Bertie Hospital’s vice chief of staff, has seen today’s patients — all five. Last night, the emergency-room physician sent another one, who had come in gripped by a worsening heart attack, straight to Greenville, 40 miles away. Vidant Bertie Hospital, North Carolina’s smallest, has six beds; Duke Medical Center, the state’s largest, has 957. Just as in Durham, patients come here sick and injured, get well and go home, and some die. But medicine in Windsor, population about 3,400, is a world apart.

As a business, the hospital is barely a blip in the state’s $70 billion-a-year health-care economy, though the 128 people on its $9 million annual payroll make it one of Bertie County’s largest employers. That’s the case in many rural counties, where one of three North Carolinians — about 3 million — live. At Bertie Vidant, care is intimate, attentive and personal, but its providers face problems nearly imponderable in big cities. Many patients are dirt-poor, some living in singlewides rusting in piney woods or houses without indoor plumbing. Some can’t read well enough to take the prescriptions Harris, 58, writes for them. Others cannot get them filled because, back home, the nearest drugstore is 25 miles away. “If they can find someone to take them, that’s 10 or 15 bucks,” he says. “That’s a lot of money here.” Diseases controllable elsewhere kill people here.

In 2001, the tiny hospital became the nation’s first to open under a new federal law. Like hundreds of others in places like this, it was at death’s door, and if these hospitals closed theirs, millions of rural Americans would be without care. Called a Critical Access Hospital, this one became a national model for the genre. The designation allows it — and 21 other of the 138 hospitals in the state — to be paid a rate based on the actual cost of treating Medicare patients rather than the fixed fees larger hospitals get. That and its affiliation with Greenville-based Vidant Health, the largest health system in eastern North Carolina, saved its life.

But laws can’t change demographics, and business models don’t redraw geography. “It’s the buckle of the Stroke Belt,” says Paul Cunningham, dean of Brody School of Medicine at East Carolina University in Greenville. He’s referring to a swath of the South where the death rate due to cardiovascular disease is 10% higher than the national average. Bertie County’s is double the nation’s. That from diabetes is nearly 50 per 100,000, three times that of Wake County. People who make it to the hospital alive find advanced technology and an emergency department that lacks for little and where, already this morning, wait some of the 25 patients it sees on average each day. About 9,000 came last year. Those needing more sophisticated care are whisked away by a helicopter dispatched from the mother ship, Vidant Medical Center in Greenville.

It was not this way when Cunningham arrived at Bertie Memorial Hospital in 1980. A native of Jamaica, the surgeon had been practicing in Harlem, and waiting for him were poverty and health crises equivalent to what he had left in inner-city New York. He recalls cradling in one arm a gut-shot boy while rhythmically squeezing a transfusion bag with his other hand to pump blood into him as an ambulance sped through the night to Greenville. “He’s still alive today.” He’s lucky. A recent study finds men in Bertie County today can expect to live 70.7 years. That’s more than eight fewer than in Wake County, less than 120 miles away.

“Rural life is supposed to be pastoral, quiet, sleepy,” Cunningham says. “But it’s not as bucolic as many imagine. People get sick, hurt, they get deathly ill. There are social determinants of health — diet, poverty, lifestyles — that affect our communities in an uneven manner. The hand of fate is not generous when it comes to people living life off the mainline.”

Time fades memories like the red bricks of buildings downtown on King Street, where sometimes late at night fog from the Cashie River shrouds the obelisk honoring Confederate dead. Most have forgotten, or are too young to know, that somewhere along here, near the florist shop with “Funeral Flowers” writ large across its front window, folks in the 1940s went to the hospital. “It had four or five beds. You walked up a long flight of stairs, and there were two retail stores under it,” recalls Robert Spivey, 85, a native and longtime Windsor mayor. He doesn’t recall its exact location, nor do any of the other old-timers he asks. “My two oldest children were born there.”

In the early 20th century, three things typically defined rural North Carolina: consolidated county high schools fed by one-room elementary schools in isolated farm communities, a few local industries that provided “a job in town” when farm work petered out and makeshift hospitals, sometimes in cavernous old houses or improvised locations such as Windsor’s. The town, designated the county seat before the Revolutionary War, had long thrived on its river trade and timber industry. After World War II, an overalls factory and wood-products plants opened. Spivey, birthed at home, got a job as an office clerk with a plywood manufacturer and worked his way to the top.  

In 1946, Congress passed the Hill-Burton Act, providing a dollar for every two a community scraped up to build a hospital. The county raised $200,000 with a bond issue and opened Bertie Memorial Hospital in 1952. Brick, three stories — now an apartment building for the elderly — its green-tile operating rooms could be easily sanitized, and it had technology such as X-rays that had only been available hours away in Raleigh or Norfolk, Va. There were 39 beds for blacks and 11 for whites. The racial demographics of Bertie County, which is 61.9% black, are little changed. “I saw the same people as in Harlem, separated only by miles,” Cunningham says. “I’m a surgeon. When I operate, the blood I see has only one color — red.” He performed cesarean sections, open-lung procedures and hysterectomies, pinned broken hips and patched up men mutilated in logging accidents. He was invited to join the Cashie Golf & Country Club, which up until then had been white-only.

But by the time he arrived, the hospital had fallen behind, lacking such new technology as high-volume surgical suction. “We had a Gomco machine,” a portable suction pump on the floor. “It would sit there humming, but it just wasn’t designed to deal with massive hemorrhaging. You have to keep your operating field clean while you work — I learned to make sure my surgical technique was almost bloodless.” The economy of the town, too, was ailing. “There were nine sawmills in the county,” Spivey says. “The overseas market took the woodworking industry away from us. The overalls factory closed.” That was in 2003, when Greensboro-based VF Corp. shut down the former Blue Bell plant. “Health care and schools are always main questions when you approach a new business or industry,” says Spivey, still a member of the region’s recruiting team. “That made it difficult for us to compete, to attract industry. We have smaller retailers like Family Dollar and Dollar General but no major retailers. And we just don’t have much of a manufacturing economy anymore.” Bertie’s $568 average weekly wage was the state’s fourth-lowest in July, behind only Hoke, Clay and Tyrrell. The last, two counties east, is the lowest at $511.

clientuploads/Archive_Images/2013/11/vidant-chart.jpgFrom 1980 to 1989, 252 rural hospitals nationwide closed, including one just two counties west. Warren County General Hospital, built in Warrenton in 1950 with Hill-Burton assistance, was plagued by low occupancy and poor management. Near the end in 1983, a visitor noticed it had a kitchen staffed to serve its 37 rooms, though it had only three patients, two of them fed intravenously. Bertie Memorial closed for about a month in 1985. “A lot of very small hospitals then had trouble with adequate management skills and infrastructure,” says Thomas Ricketts, a public-health expert at UNC Chapel Hill. It reorganized and reopened, but young people were fleeing the region for futures elsewhere, leaving mostly older, sicker patients and Medicare’s tightening noose.

“By the early 1990s, small, rural hospitals were going bankrupt at an alarming rate,” says George Pink, a senior researcher at Cecil Sheps Center for Health Services Research in Chapel Hill. Prospective payment, which began in the 1980s and is again in the spotlight as the Affordable Care Act is phased in, dictated set payments for procedures and penalized hospitals for readmissions. A hospital’s share of an appendectomy might be $9,000. “It didn’t matter if you were there five days or 20 days.” Small hospitals had no cushion for fluctuations. “If you’ve got an 800-bed hospital, your census might be 600 one day and 580 the next, a swing of 3 or 4%. At a small hospital, the change from six to three is a 100% swing, but all your costs are fixed. You have to have doctors there, nurses there.” In 1997, the Critical Access standard threw a lifeline: These hospitals had to be 35 miles from a major medical center, have no more than 25 beds and an around-the-clock emergency room and serve relatively short-term — 96-hour maximum — patients. Instead of being throttled by fixed fees, they would get 101% of actual costs for Medicare patients, the bulk of their cases.

Bertie Memorial faced other obstacles. “The county brought in several management firms but still couldn’t turn it around,” says Spivey, a former county commissioner. “Then we brought in University Health Systems, and through good management they got it on firm footing. But even with that, they knew in the future they couldn’t keep it up as standards changed.” Should Bertie give up the old hospital it had nurtured nearly half a century? “People still want local health care,” says Mary Piepenbring, vice president of Charlotte-based Duke Endowment, which has awarded hundreds of millions of dollars to build and equip rural hospitals in the Carolinas since 1924. “It might be inadequate — and if your mom’s there, you might want her to be elsewhere — but it’s an emotional decision for a community. When you talk about joining a larger system, there’s this huge issue of trust.”

In 1998, University Health Systems of Eastern Carolina Inc. — it changed its operating name to Vidant Health in 2011 — took over Bertie Memorial. Part of the deal was building a $10 million, 48,000-square-foot Critical Access Hospital. Harris, the physician, sits in one of its break rooms, preparing to meet patients in the rural health clinic. He grew up in Durham and trained at Brody School of Medicine, established in 1969 to turn out primary-care doctors for eastern North Carolina. On a state scale, Vidant Bertie’s numbers are tiny: In the last fiscal year, its staff admitted 452 patients, performed 759 surgeries and saw nearly 25,000 outpatients. “Without Vidant? We wouldn’t be here. We’d close down,” Harris says. “The county here is very savvy. They understood before a lot of others that to survive, you simply have to affiliate with a larger system.”

Net operating revenue grew to $17.2 million last year from $16.2 million in 2011, though that’s still nightstand change compared with Vidant Health’s more than $1.3 billion. But the 27-county health system emphasizes local control, which helped ease community angst. Other benefits are intangible but real, too. Harris practiced in the Triangle and Wilson before coming here. “I might make more money in a bigger place, but I’m well compensated by Vidant. For me personally, here I have a lot of autonomy I wouldn’t have there. I enjoy it.”

The surgeon who preceded him by more than two decades weighs the costs and contributions of rural hospitals, including Vidant Bertie’s almost $900,000 in charity care in 2012. “The people of Bertie County deserve the same level of care as those in Charlotte or Raleigh who live right next to a sophisticated medical center,” Cunningham says.

Achieving his ideal of care isn’t easy in a place like Bertie. West of Edenton, the four-lane highway arches over the Chowan River and hurls traffic toward Windsor. Its passing buffets a woman walking on the shoulder, following a map that exists only in her mind. Left behind — again — are her husband, their cat and a fluffy Shih Tzu. “We live right on U.S. 17, and she’d just walk off,” says Bill Williams, 77, as steam from the plant he guards in Merry Hill rises in the air behind him. The hospital probed. She was only 64. Metabolic causes? Medication effects? “Finally, they told me, ‘You’re going to have to put her somewhere she can’t get hurt.’”

Rural hospitals are responding with new buildings and technology but are engulfed by what Piepenbring — a former executive at Charlotte-based Carolinas HealthCare System, the nation’s second-largest public hospital network — calls “the silver tsunami.” “Most of our patients are over 65,” Harris says. And most, Vidant Bertie Marketing Director Megan Booth-Mills notes, show signs of dementia. Renee White, the hospital’s medical and surgical nursing manager, tries to mend the consequences. “Older patients sometimes have to decide if to pay light bills or buy medicine. Some have conflicts with their families over whether to put them in nursing homes. That might represent income that families won’t have anymore, plus in rural communities you don’t want to put mom or dad in nursing homes.”

More often than their urban counterparts, Vidant Bertie and similar hospitals reach out to patients — nearly half are visited at home after discharge — with education, help with medications and similar programs. But young or old, rural cultural differences go beyond stereotypical. “They’re proud,” says Melissa Snyder, transitional-care nurse. “They’ve worked all their lives, and accepting something they consider charity is sometimes worse than their illness. They get depressed.” Another rural trend: more suicides. Coping with human and economic frailties is often more of a challenge than once-inadequate medical equipment and training. Technology, after all, has diminished some of the dangers inherent in distance. Bob Spivey knows that first-hand.

He opens his eyes and looks up at a quilted, cushioned ceiling a few feet above his face. He feels motion, like an elevator. Less than an hour ago, after a morning working in his yard and a shopping trip to Edenton with his wife, he was on the way back when the pain started. He drove straight to the hospital, where an electrocardiogram told him what he already knew: heart attack. Minutes blur. Now, he hears a voice inside his helmet. A nurse smiles down at him. “I remember her saying, ‘We’ll be there in 18 minutes.’” In less than an hour from the time he walked into the hospital in Windsor, medics at the helipad atop the hospital in Greenville are rushing him to intensive care for quadruple bypass surgery.

Medical helicopters are revolutionizing rural health care, closing the gap between remote residents and the medical-center level care Cunningham says they deserve. Federal Aviation Administration records show more than 50 helipads, mostly at remote hospitals and clinics, in North Carolina. Vidant’s fleet, the state’s largest, flies more than 2,400 missions a year, including one or two a week to Vidant Bertie. “On my last shift, I had an elderly lady with a dissected aneurism” — a potentially fatal tear in the aorta, says Billie Threlkeld, the emergency-department physician. “Once it would have taken two hours. They had her in the emergency room in Greenville being evaluated in 30 minutes.” Helicopters, however, are limited by weather, expensive — bills exceeding $15,000 are common — and, despite their speed, sometimes not fast enough. “Some patients require care in minutes,” Cunningham says. “We could launch F-15s, and it wouldn’t matter — we’d still lose them. You need the care embedded in the community in which people live.”

That too, however, is increasingly coming to rural hospitals. Telemedicine, telepsychiatry and teleradiology are staples at Vidant Bertie. Booth-Mills leads the way down one hallway where radiologists are transmitting X-rays to Greenville for immediate interpretation. Mammograms and similar images are read first here, then again in Greenville. In another clinic, patients in white gowns nervously await colonoscopies, to be interpreted here or at Vidant Medical Center. The hospital has a trained stroke team for a potentially devastating condition that requires immediate care. But despite the benefits of affiliation, that’s sometimes not enough to save a hospital. In September, Vidant Health began phasing out its 49-bed Critical Access Hospital in Belhaven, citing its age and site in a flood plain. Another, though not determining, factor was the state’s decision not to expand Medicaid.

At the state’s littlest hospital, the new week begins with old contradictions and contrasts. By afternoon, morning’s mist turns to sunshine, and a clutch of children play in their corner of the waiting room under mobiles of birds and ships with rainbow sails. But no babies were born here last year. And across the way in the Vidant Bertie complex at Windsor House, a woman waits for her husband. “Some Sundays, when I’m not working, I pick her up, and we go to church,” Bill Williams says. “We’ll go by the house, where the animals are. She likes that. But we’ll be there for 30 minutes, and she’ll say, ‘I want to go back.’”