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Rural hospitals are pulse of community

Radiology Supervisor Treavor Kattick
Radiology Supervisor Treavor Kattick, who is originally from Orlando, Fla., works with the hospital’s new 32-slice CT scanner.

by Luann Dart

At first glance, Jacobson Memorial Hospital Care Center (JMHCC) in Elgin is just like any of the 36 small-town critical access hospitals in North Dakota: an imposing brick building that’s the heart of the community, where a provider pauses in the hallway to ask about a relative or a nurse offers a heartfelt hug. Where aging structures and flatlined finances still translate into topnotch medical services in rural North Dakota.

But there’s also a slightly different pulse at JMHCC. The hospital’s CEO is just 31 years old, but is leading JMHCC through a national pilot program and a $1.4 million renovation project which has rallied the community.

On Fridays, you might not find JMHCC’s Chief Executive Officer Theo Stoller at his desk. But he’s not swinging at a golf ball on a Friday afternoon. Instead, he’s been paged for ambulance duty, serving as a volunteer emergency medical technician (EMT) with the local ambulance service since 2014.

“It was a needed service and it gave me the opportunity to see it from a different perspective, from the patient care side, and to understand what the staff was having issues with and what the staff was doing well,” he explains about his volunteer service.

As the only medical facility in Grant County, with a population of 2,400, and the only hospital within 80 miles, JMHCC handles about 650 emergencies a year. JMHCC’s four providers see 7,500 clinic patients a year at its affiliated clinics in Elgin and Glen Ullin. And they know each as a neighbor, not a number.

“I’m most proud when we’re able to save a life, when we’re able to impact a family member and when that family can come back and say thank you for your service and for serving our service area proudly,” Stoller says. “There have been situations where it brought tears to my eyes to know we saved a patient’s life. That’s what keeps me going and that’s what I’m proud of.”

The ambitious CEO came to JMHCC fresh out of college with a degree in human resources management. He served as the hospital’s human resources director from 2008 to 2013, when he was tagged as CEO. He helps at the family farm during calving season and has led the 85-member staff at JMHCC through a recent $1.4 million renovation project that updated the facility, expanded the number of clinic exam rooms and placed new equipment, including a new 32-slice CT scanner.

With a 40-year-old building, JMHCC’s renovation follows a statewide trend.

North Dakota Hospital Association President Jerry Jurena points to critical access hospitals in Williston and Tioga undergoing major renovations and Dickinson completing a new hospital within the last five years. Bowman, Hazen and Watford City are all building new critical access hospitals.

“You’re seeing a lot of discussion around the state about putting up new hospitals,” Stoller says. “That’s because the buildings are getting older and they’re running out of depreciation and that’s going to be the struggle eventually.”

Stoller places physical plant among the top three challenges of a critical access hospital, among workforce recruitment and financial sustainability.

Financial sustainability must come from nonoperating revenue, he says.

“In the critical access world in North Dakota, it is very difficult, if not impossible, to make it just off of operations,” he says.

Foundations, local tax levies, grants and donations sustain most small-town hospitals.

“Those are the things that really assist hospitals to push them over the edge on the operational end,” he says.

“We’ve been very fortunate,” he says. “Anytime there’s an ask in the community, organizations have been a big supporter of what we’ve been able to accomplish here.” Mor-Gran-Sou Electric Cooperative and West River Telecommunications, which serve the Elgin area, have both donated to the renovation project, and other local organizations such as the Elgin Lions Club, the city sales tax committee, First International Bank and Trust in Elgin and Dakota Community Bank in New Leipzig have been supportive. Over the last four years, JMHCC has also acquired approximately $800,000 in grants.

North Dakota’s 36 critical access hospitals are paid based on their cost of operations, as set by the Medicare Cost Report that is completed annually, Jurena explains.

“One issue is the cost that is reimbursed is not the total cost or true cost. It is what Medicare will reimburse, which is approximately 92 percent of the total cost,” he says. “What does this mean to the hospital? It means for every Medicare patient served by the hospital, they are not paid their total cost for taking care of that patient. This is one issue that all critical access hospitals have in common.”

Now, JMHCC has expanded its number of in-patient hospital beds from 25 to 30 through a Frontier Community Health Integration Project (FCHIP). The national pilot project is overseen by the Center for Medicare and Medicaid Innovation.

JMHCC is the only critical access hospital in North Dakota selected for the project, and one of only three in the nation. By applying for the bed expansion waiver, JMHCC now offers an additional five beds that can be used at a skilled or intermediate level of care.

The FCHIP aims to develop and test new models of integrated, coordinated health care in the most sparsely populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures.

If JMHCC’s pilot program proves to be efficient while still maintaining quality, it could impact the number of beds at other facilities across the nation. 

Other critical access hospitals are limited to 25 beds. When the flu season struck the area, JMHCC was at capacity at 30 beds. Without the additional beds, local patients would have been transferred away from home.

“We want to make sure we take care of all our community members,” Stoller says.

JMHCC took another innovative approach to its patient beds in 2013, when it delicensed its nursing home, which was within the hospital. Many facilities combine a nursing home and hospital under one roof or organization, Stoller explains. But that means they must meet two sets of regulations and have two sets of staff on duty.

By switching to just hospital beds, JMHCC can still keep long-term residents in a swing-bed situation and be more efficient with staffing.

“This is the right way to do it for us,” Stoller says.

JMHCC has taken innovative approaches to workforce in other ways.

Press a button, and a doctor virtually steps into the emergency room – even though the doctor is more than 400 miles away.

JMHCC utilizes an innovative concept called eEmergency offered by Avera McKennan Hospital in Sioux Falls, S.D. The technology links Avera’s emergency-trained staff of nurses and doctors located at a central hub in Sioux Falls to subscribing rural hospitals through two-way video technology.

With a push of a button, local staff has immediate access to physician-led emergency care, additional support for local providers or simply answers to questions.

To use the eEmergency services, the local nurse or doctor pushes the call button, and dials the central hub in Sioux Falls, which is staffed 24/7. Within 20 seconds, nursing staff and a doctor appear on the monitor in the local emergency room. The two-way video and audio link allows the Avera staff to converse with the local staff. Avera staff can use the camera to zoom close enough to examine a patient’s eye or read a piece of paper across the room.

“That’s one thing we don’t know what we would do without anymore,” Stoller says. Having a board-certified emergency room physician to guide nurses until the local doctor arrives, or offer a second opinion, is valuable in keeping patients local.

Like every critical access hospital, staff recruitment is an ongoing challenge.

“Every facility is looking for nursing, every facility is looking for some type of speciality health, whether it be in lab or radiology or wherever,” he says.

Like many North Dakota hospitals, JMHCC has four-year agreements with staff members from the Philippines, who are using the work opportunity to pursue citizenship.

“A lot of facilities are going that route,” Stoller says. JMHCC has been able to add two nurses and a dietary aide through the program.

“It is not easy in any size hospital, they all have the same issues: reimbursement and staffing,” Jurena says. “There are different nuances in each location, but the issues are the same.”

“What separates us from any other hospital is the staff that we have here in the community. We wouldn’t be able to do anything we do without our board of directors and our staff,” Stoller says.

The facility treats everything from the sniffles to providing end-of-life care, which often takes an emotional toll on the staff. Stoller describes the loss of two end-of-life patients within hours of each other.

“A lot of people were emotional, I was emotional. It was a hard one, but we do better care because it’s from the heart,” he says.

Every morning, Stoller walks through that imposing brick building, taking the virtual pulse of those inside – greeting patients by name and visiting with staff.

“The reason I do what I do is the patients we serve and the communities we serve. I have a lot of motivation. Every single day. I walk upstairs and I visit with the patients and make sure we are taking good care of them,” he says.

Luann Dart is a freelance writer and editor who lives in the Elgin area.