The Realities of Rural Healthcare
How a 16-bed hospital and a group of dedicated doctors, nurses and paramedics manage the health and emergency needs of North Country residents and tourists
About four years ago in January, after loading hay for her horses into her truck, Kim Hamel felt crushing pressure in her chest and a disconcerting “electric” sensation. She went into the kitchen of her Colebrook home and dialed 9-1- — but then she hesitated. At only 42 years old, and with no known history of heart trouble, she couldn’t believe she was having a heart attack, but at the same time instinctively felt certain that she was. “I knew it was a heart attack somehow,” she says today.
She eventually did call an ambulance and, soon after arriving at nearby Upper Connecticut Valley Hospital (UCVH), she blacked out and went into cardiac arrest. Health providers performed CPR and used a defibrillator to get her heart pumping again. If there hadn’t been a hospital so close by, she says, she surely would have died.
Unlike many readers of this magazine, who might be able to get to a hospital in 10 minutes — maybe 15 with traffic — people who live in the North Country or other remote region might find that quickly getting to medical care isn’t so simple.
Turns out the hospitals in remote areas don’t have it too easy either. After an alarming number of rural hospitals went belly up in the ’80s and ’90s, the Centers for Medicare & Medicaid Services (CMS) began to offer a “critical access hospital” designation to rural health facilities that meet certain criteria. In return, those hospitals get financial breaks here and there to help them keep their doors open.
UCVH in Colebrook is a prime example of a critical access hospital. With only 16 beds, it is the state’s smallest hospital. But to people who live nearby — and to the many tourists who unexpectedly find themselves in need of medical care while visiting the area — it’s hugely important.
“We are kind of the poster child for a critical access hospital,” says Edward Laverty, PA-C, chief medical officer and an emergency medicine specialist at UCVH. Unlike some critical access hospitals that receive exemptions, “we’re actually the only hospital in the state that meets the true criteria for critical access hospitals,” Laverty says. “It’s something we’re very proud of.”
UCVH serves an area that covers 850 square miles, 20 communities and more than 8,000 residents, extending up to the Canadian border and into parts of Vermont and Maine. The hospital provides routine care, but also treats trauma patients, including many victims of car or motorcycle crashes, and ATV and snowmobile accidents. Some receive their care solely at UCVH, while others are transferred to tertiary care locations, including Dartmouth-Hitchcock in Lebanon, Maine Medical Center in Portland and the University of Vermont Medical Center in Burlington. “A lot of times when the weather’s bad, the [medical] helicopter can’t fly,” Laverty says, “so the trauma patients come to our facility, [where] we treat, stabilize, and then transfer them to a tertiary care trauma center.”
During weekends, UCVH sees “a huge influx” of trauma patients in its emergency department, Laverty says. The ER’s summer numbers have also been on the rise as an increasing number of trails open for ATV use.
“And that’s just the tourism part,” Laverty says. “The local community relies on us very heavily for their medical care.” According to UCVH’s website, the ride to Colebrook takes an hour from the farthest reaches of Coös County — not a short drive, but matters would be significantly worse if UCVH didn’t exist, with some area residents having to travel well over two hours to reach Dartmouth-Hitchcock or Manchester’s Catholic Medical Center. “And if you’re having a heart attack,” Laverty says, “that’s not very good timing.”
Laverty likens UCVH to a MASH unit, an isolated surgical hospital that serves soldiers wounded in warfare. Only in UCVH’s case, emergency patients come in not with battle wounds but with injuries sustained in motorcycle, snowmobile or ATV crashes, or in the midst of cardiac arrest or other medical emergency.
Despite the crucial role that critical access hospitals play and the assist from CMS, many of them struggle to remain open. Some form partnerships with a larger healthcare group, as UCVH has with North Country Healthcare, to pool IT resources and gain other advantages, but many rural hospitals find that they have no choice but to cut back services. In 2003, for example, UCVH closed its obstetrical care unit. Scaling back OB services is not uncommon among critical access hospitals, given the overall expense involved and insurance carriers who require a premium due to the high-risk nature of obstetrics at a rural hospital. “If you’re not doing a lot of deliveries, it makes the deliveries you are doing more risky,” Laverty explains.
Finding people to staff rural hospitals is also a challenge. “Recruitment and retention is probably one of the hardest things that we do,” Laverty says. “It always sounds good when I first interview people. They’re like, ‘Oh, it’d be so great to work there,’ but then they get here and they’re like, “Wow, you’re hours from an airport. There’s really nothing here.’” Most often, he says, providers quit or turn down a job offer because their spouses find that in the Colebrook area “there’s not much for them to do.”
The healthcare providers who choose to remain face some tough realities. When it comes to social determinants of health — regional characteristics such as the average income, education, employment status and availability of social support networks — the North Country checks all the wrong boxes, Laverty says. “We’re kind of number one [in the state] for cancer rates, we’re number one for alcohol [abuse], we’re number one in tobacco abuse.” Diabetes and opioid addiction also have strong footholds in the area, he says, and the average age continues to climb as more retirees relocate to the area while young people stay away due to the limited OB and other services and the scarcity of jobs — particularly following drastic cutbacks at two of the area’s major employers, The Balsams and Ethan Allen. These health-related features of the area simultaneously complicate matters for UCVH and underscore the importance of its existence.
The hospital’s financial worries include its many patients who don’t have health insurance, and the lack of community resources for patients, says Lindsay Lea, RN, chief nursing officer at UCVH. “We won’t discharge a patient unless we have a safe discharge plan for that patient.” Patients might lack a safe discharge plan because they’re homeless or isolated, or they’re unable to make important decisions and there are no available community resources to help. In such instances, sometimes patients who don’t have a medical need to be in the hospital remain there anyway, Lea says, creating “significant expense” for the hospital.
But UCVH remains steadfastly focused, Lea says, on the needs of the community. “I think there’s a perception on the part of some patients that if you need medical care, bigger is better — that at bigger hospitals, they must know more about what they’re doing and what you need. And I think that we prove every day to our community that that’s not always true.”
Although Lea says UCVH is “pretty judicious about [spending], because we have to be,” the hospital doesn’t skimp on needed equipment. It offers the latest in mammography technology, for example, and has upgraded its CT equipment so that patients are exposed to lower doses of radiation. “Those are things that I think the population really wants,” Laverty says. “They expect the same care at their critical access hospital as they do when they go to Dartmouth-Hitchcock.”
In addition, since the 1990s, UCVH has employed telehealth technology to supplement in-house services and knowledge with expertise from Dartmouth-Hitchcock, Catholic Medical Center, Androscoggin Valley Hospital and Northern Human Services. Teleradiology enables UCVH patient imaging such as X-rays and CT scans to be read remotely by doctors at Dartmouth-Hitchcock, and UCVH uses telehealth in its emergency and pharmacy departments, and for behavioral health and other services. The telehealth programs “allow us to potentially keep the community patients here that we’d normally have to send out because we didn’t have the specialty,” Laverty says.
UCVH also offers a specialty services clinic, where OB/GYN, neurology, cardiology, and other specialists come regularly to spare patients a long drive. The decision to host visiting specialists was made after “we noticed that was a gap [in patient care],” Lea says. “Transportation is hard up here, and there’s not a lot of resources for patients who are having a difficult time.”
Given the tenuous existence of some rural hospitals, do area residents worry about what life would be like if UCVH closed its doors? “Absolutely,” Laverty says. “I work in the emergency room, so I get to hear on the front line about how thankful people are that we’re here.”
Indeed, community members have shown their support for the hospital, helping UCVH to raise just shy of $1 million a couple of years ago, Laverty says, for an upgrade of the hospital’s emergency and physical therapy departments, among other areas. “So many people are so appreciative of being able to have their healthcare locally,” Laverty says. “And people from away, they can’t believe how upgraded and modern and sophisticated our equipment is.”
Those from out of town also marvel at how quick the ER wait is at UCVH. “I had one guy actually tell me he wants to drive up from southern New Hampshire the next time he needs to go to the emergency room,” Laverty says with a chuckle, “because it’d be quicker for him to drive up here to be seen” than it would be for him to go to his local ER.
For Laverty and Lea, working at a critical access hospital appears to be a passionate and personal mission. “Some of it’s the adventure, the challenge, because I don’t have all the consultants and I don’t have all of the specialists at my fingertips, so I really and truly have to be a jack-of-all-trades and a MacGyver,” Laverty says. “I wake up every day looking forward to going to work, and when I’m not going to work, I’m kind of bummed … I think UCVH is very important to the North Country, and for everyone [who visits the area].”
Lea got her first glimpse of working at UCVH through a school-to-work program when she was a high school student growing up in Colebrook. “I was just enthralled by it,” she says. “I was so impressed with the care that they provided — they did so much with so little. … I knew I wanted to work in my community and make a difference here, and I think at a small hospital you [can] do that.”
Which gets to the heart of what can set a small rural hospital apart from larger city facilities: “It doesn’t have a whole lot to do with medicine or equipment,” Laverty says. “It’s the personal touch. It’s knowing people and people knowing you, being able to see them and be with them at a personal level and helping them at a time of need.”
Laverty notes that UCVH’s nursing staff provides “extra TLC” for patients, and properly cleans people who come in from an accident — which, based on his experience, does not always happen at bigger hospitals, where he says some patients are left with “blood or glass in their hair because nobody took the time to wash them thoroughly.” When patients come to UCVH, he says, “we treat them like they’re our friend and neighbor — because they are our friends and neighbors.”
“We not only care for our community, we care about our community,” Lea says. “Not to say that bigger hospitals don’t [do the same], but at a smaller hospital there may be that much of a stronger connection. I think that we do a really good job of providing exceptional care but also excellent customer service because we’re treating our own, you know? It’s who we are.”
Lea adds that, following transfer to another hospital, many patients who return to UCVH for rehab or skilled nursing care echo the same sentiment: “‘I’m so glad to be home.’”