Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week.
I learned about Alleghany Health from Dr. Kae Livsey, Professor of Nursing at Western Carolina University (WCU). Alleghany Health is a Critical Access Hospital — a term designated by the federal government for remote hospitals that provide critical service to rural communities — that serves Alleghany County, North Carolina.
Earlier this year, Dr. Livsey brought WCU nursing students to the hospital so they could experience the kind of wraparound work performed every day by rural nurses in medically underserved communities.
According to her, the students learned a lot. One student, she said, worked with a patient who came in for primary care, then went to the emergency room, then got admitted to the hospital, and finally got discharged, “all in the three-day period we were there.”
In the midst of a dire staffing crisis for the hospital, Dr. Livsey and Alleghany Chief Administrative Officer Kathryn Doby had a theory that if students could see the inner workings of a Critical Access Hospital, they might feel called to the work. And while the struggles faced by such hospitals are structural in nature, Livsey and Doby saw their idea borne out on a micro-level. “When we were about to leave,” Livsey said, “I asked the students, ‘What was your takeaway?’ and some of them told me, ‘You know, I think I could see myself working somewhere like that one day.’”
I spoke with Kathryn Doby about the set of circumstances in which that partnership was created and how Alleghany Health have handled the pandemic. Enjoy our conversation, below.
Olivia Weeks, The Daily Yonder: Can you start with describing the organization you work for, where it is, and what’s unique about it?
Kathryn Doby: Alleghany Health is a generic name for Alleghany Memorial Hospital and Alleghany Health outpatient clinics. It’s a small Critical Access Hospital in the rural mountains of North Carolina, in a county of about 12,000 people. So it is a small facility, and as with all small rural health facilities, it struggles greatly with financial solvency and stability. But we’ve done a lot of construction and work up here rebuilding programs. We offer inpatient, 24/7 emergency department care as well as imaging labs. We have a robust outpatient clinic program for internal medicine, primary care, and specialty care services.
DY: How long has this Critical Access Hospital existed and what was there before?
KD: The hospital itself has been here probably around 50 years. Previously, it was primarily a hospital. It had 41 licensed inpatient beds and was the primary source of hospitalization for the residents of this county. But over the course of decades, of course, that started to decline as patients needed tertiary care that they can’t get here — meaning specialized care at a trauma center or at a facility that has intensive care units, which this hospital did not have and does not have.
Over the course of time, what’s happened in rural health is that hospitals have stopped trying to be everything to everybody and started kind of re-creating themselves into what the community really needs. So a Critical Access Hospital means just that: it is critical access for the residents of the community. And when that designation came about, that changed the way in which we treat people. In cases of trauma, accidents, injuries, as well as, you know, severe medical crises, we stabilize patients. If we can keep them and care for them here, we do, meaning if they don’t need a specialized unit. If they need that, we transfer them to a larger system facility where they can get that care, but this is their first stop because local emergency medical services is going to take you to the closest hospital in an emergency.
DY: I wonder if you could tell me about what the biggest challenges were throughout the pandemic and how you guys are faring now in relation to those challenges. How has your service changed over the past few years?
KD: The pandemic was, as I’m sure you’ve read, a disaster for all health care. And if you speak to a small rural health facility or a Critical Access Hospital, what that meant was, we had lots of patients coming here because the other facilities were either full — their beds were full, their intensive care units were full — or they were understaffed. We had nowhere to transfer patients during the pandemic, and we still encounter that. Our difficulty is that those patients are requiring services that we cannot provide. So we are trying to maintain those patients and keep them stable in an emergency department that is not designed for that.
Throughout 2020 and 2021 we were inundated with very, very sick people. There’s a high incidence of lung disease in this area anyway, so when Covid was primarily characterized by respiratory illness, that created additional challenges for those individuals who came here. Many of them you could not find or get them into a bed quickly enough at a larger facility where they could get intensive care or respiratory treatment.
So we went through all of that, and then there’s this fallacy that the CARES Act money came out and everybody got wealthy off of it. And what I can tell you is that the CARES Act money was based on prior Medicare reimbursement, which is why different facilities receive different amounts. So the amount that we received was proportionate to our billing amounts. It was certainly beneficial, meaning it did allow us to give Covid pay to staff, to buy Covid supplies and all those various things. But it also created a tremendous amount of work for our one-person accounting department.
Of course, throughout the pandemic we never closed. We didn’t shut down, we didn’t close, we didn’t shelter. We had to stay here, so all of us were here throughout everything, and you’re trying to take care of patients, you’re trying to take care of the stuff you need to do, but you have these additional layers of work on top. By the time you start to come out of that, it’s a few years later. So that’s where we’re at now. That leads me to my final comment, which is that right now the community and the public at large, you know, thinks that Covid is here to stay, but it’s basically okay, right? It’s become the flu. But there are major after effects of all of this, and we’re still wondering, “How do you get back to core business? How do you get back to building and rebuilding your finances? How do you get back to staffing?”
All of those challenges are still here and aren’t readily visible to the public. So they’re thinking, “Okay, it’s business as usual.” But we’re still trying to catch up.
DY: What is the situation like currently with transfers to other hospitals? You mentioned that being a big problem during the pandemic when other hospitals were full. Is that still an issue, getting your current patients the care they need elsewhere?
KD: It is better, but it is still an issue because most of those facilities are understaffed. Therefore, they have fewer beds that they can staff. So you know, when they say “we’re full,” the beds that they have the adequate nursing staff to manage are full. So they’re not operating at full capacity at this point, and neither are we. I mean, we don’t have the nurse staffing that we need either. It was during the pandemic that I reached out to the North Carolina Health Care Association, about getting nursing support. And, you know, other than travel nurses, which they were very helpful about connecting us to, there was no solution.
The other thing I started asking was, “How do we build relationships with educational institutions to support recruitment in a rural setting like this one?” That’s how the relationship between us and Western Carolina University’s nursing program came about. It was the product of a few years of work by Kae Livsey and myself. It didn’t happen overnight.
So this year is the first year that we’ve actually finalized a program and they’ve been able to send a group of students. And it was a wonderful experience, truly, all the way around. They were really impressive.
DY: You said that during the pandemic you were connected with resources for trying to get travel nurses to the area. Can you just talk about what your current staff recruitment looks like? How many of the people working at the hospital are from the county where they’re working? And how much are you guys trying to pull from elsewhere?
KD: Well, we still have vacancies. I think right now we have four, which doesn’t sound like many but keep in mind that we only run two RNs per shift in the inpatient and emergency department settings. So four is a whole day, at least, that we can’t staff. And we’ve only had two travel nurses since 2020. That’s because of funding. We cannot afford travelers. There’s just no way. The only two times that we’ve engaged with travelers is once in 2021 and then again now. And it’s simply because we’ve been recruiting for so long, and we simply can’t keep the doors open.
That’s kind of what gets lost in a small setting. In a larger setting they can shut down units and redeploy their staff. We can’t do that. We only have one unit and one emergency department, so we have to keep enough staff out there. We’re struggling to keep the minimum number of nurses we need to keep the doors open. And that’s been our challenge all along. Other facilities that were larger were able to reorganize their resources, I mean they struggled and they suffered, but they were able to shut down units. We can’t do that. If I shut down the unit, I shut down the hospital.
DY: Right, so it’s clear you’re still catching up. But what are the priorities now? What’s the game plan?
KD: I mean, I’ll say it again: staffing. It’s a small county, and there aren’t any educational institutions that provide fully-trained health care workers. We’re on top of a mountain in a very rural area where 80% of the population is geriatric. We have very little infrastructure for business. It’s a retirement community. So you don’t have professionals moving into the area, and therefore there’s very little to recruit from. We’re essentially trying to recruit from larger areas, and it has to be somebody who says, “Yes, I want to live in a very rural area and work in a very small hospital.” And that’s rare. So staffing is and always will be an issue for a very small area.
The only way to try to build a cadre of people is through those educational programs where you have interns coming through or students who might be interested in rural health care. So staffing is a huge issue all the way around and an expensive issue, because it’s a vicious cycle. Because you also have to worry about your existing staff who have been here since day one and are just beyond tired.
Secondly, you’re trying to recover financially, while understanding that Critical Access Hospitals and rural hospitals in general are always struggling financially. So the larger systems again started out in a better place financially than rural hospitals did. Rural hospitals are at risk across the nation, and, you know, as you can Google anywhere, numerous hospitals have closed over the course of years in rural communities.
Next, reestablishing all of your programs, those that were closed, those that were understaffed, those that you didn’t have equipment for, we’re still trying to get all those back up. Perhaps even more importantly than everything I just said, it’s reestablishing that relationship with the community and saying, “This is the new health care environment. How are we all going to be able to deal with this and how are we going to manage it together?”
I know it sounds gloom and doom, but it’s not. Because it’s also a labor of love. And that’s what I think is most important for people to know: health care providers in rural communities are your neighbors. These are people that you know and go to church with and see at athletic events and your kids know each other. They’re all here to take care of each other. And that’s the goal, that we continue to be able to do what we need to do for the surrounding community residents, that they have a place where they can come in a crisis.
This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.