A few weeks ago, a woman gave birth at Hereford Regional Medical Center, a critical access hospital in the Texas Panhandle.
Or, rather, the woman gave birth in the parking lot at Hereford Regional Medical Center after driving over an hour to get there, according to Jeff Barnhart, the hospital’s chief executive.
Barnhart said he’s heard it all over the years: patients giving birth at rest stops and in ambulances and in the car on the side of the road. The hospital’s patients come from a 1,600-square-mile area in the Texas Panhandle, and some of them just don’t make it in time.
But now, even patients who do make it to the hospital have another variable to contend with: critical staffing shortages and exploding COVID-19 case counts. There are days when Hereford Regional doesn’t have enough nurses to operate the labor and delivery unit, forcing it to divert patients 50 miles northeast, to Amarillo.
“We give them a medical exam and see if there’s time to get them in an ambulance to another hospital that can take them,” he said. “But sometimes, that baby’s coming and there’s just not time.”
Those patients give birth in the emergency room, an increasingly common occurrence as rural hospitals limit or cease labor and delivery services due to insufficient staffing.
Nationally, the health care system is facing an unprecedented labor shortage as nurses retire, resign, burn out or leave staff positions for more lucrative travel nursing contracts. Rural hospitals, many of which already operate with a shoestring staff, are especially hard hit.
Declining populations and cuts to Medicaid and Medicare funding have made Texas the national leader in rural hospital closings, with some 26 closures — permanent or temporary — of rural facilities in the last decade. Two-thirds of the state’s 157 rural hospitals are public, which means less flexibility in salary negotiations. Administrators also say it’s often difficult to recruit medical personnel to smaller towns in remote counties.
Struggling to survive, the remaining hospitals in Texas’ rural communities have had to cut back services. And when that happens, labor and delivery is often the first to go.
Only 40% of Texas’ rural hospitals still have a labor and delivery unit, according to the Texas Organization of Rural and Community Hospitals, leaving whole swaths of the state without access to nearby obstetrics care.
“If we’ve got nurses to cover a day, of course, we’re going to try to take care of everything that we can here,” Barnhart said. “But it’s just a scheduling crisis, and whenever we can’t make it work, we just let the hospitals in Amarillo know so they can expect it.”
Cuts to services
Adrian Billings has been delivering babies at Big Bend Regional Medical Center for 15 years, serving patients across a 2,000-square-mile area in West Texas. The hospital delivers about 200 babies a year, he said, with pregnant patients sometimes driving over 100 miles to give birth.
But in recent months, for the first time since he’s worked there, the hospital has limited the hours the labor and delivery unit is open. Over the holidays, the unit shut down entirely for two weeks. For a while, it was only open Monday through Thursday morning.
“When that happens, essentially, it’s a maternity care desert Thursday morning through Monday morning out here,” he said.
He said the hospital tried to schedule inductions during the week as much as possible, but childbirth can be hard to predict. If a patient goes into labor during the off hours, they either give birth in the emergency room or are sent 60 miles away to Fort Stockton.
A spokesperson for Big Bend Regional said in an email that the hospital recently hired additional nurses who will soon allow it to resume full-time maternity care. But many rural hospitals say they simply aren’t able to keep up in today’s ultracompetitive labor market.
“We only have six doctors at our hospital,” said Jennifer Liedtke, the director of the labor and delivery unit at Rolling Plains Memorial Hospital in Sweetwater, about 40 miles west of Abilene. “When you’re talking about a census of 20-plus patients, we’re carrying a full load trying to get everyone seen. … It’s rough.”
Rolling Plains typically tries to have three labor and delivery nurses scheduled for each shift. But recently, Liedtke said the team is scraping by with one nurse and a shift supervisor who can step in as needed. Her nurses often get pulled into other units when there are no deliveries.
“There’s not a patient back there today, so both of [the nurses] are working the COVID unit right now,” she said. “So if we do have a patient come, they have to go shower and change into all new scrubs and stuff before that patient will have to come back.”
Many of the longtime nurses at Rolling Plains retired during the pandemic, Liedtke said, and it’s been difficult to find replacements. On Monday, all five of the hospital’s ICU beds were occupied, according to state health numbers.
“We’re trying to recruit right out of school right now, but a lot of the young nurses are going into travel nurse positions,” said Liedtke, who is also a family physician and OB-GYN. “They can sign big, big contracts … and that’s just not something we’re going to be able to match.”
Liedtke said it’s especially difficult to recruit nurses to work in the obstetrics unit of a rural hospital. At a larger facility, there might be different nurses dedicated to labor and delivery, the nursery, and postpartum care. But at Rolling Plains Memorial, one nurse has to handle all those roles.
Labor and delivery is a major investment for rural hospitals, requiring specialized nurses and a recommended 2-to-1 nurse-to-patient ratio during delivery. It’s rarely a money-making enterprise for these hospitals, particularly if they’re serving uninsured or Medicaid patients.g
John Henderson, president of the Texas Organization of Rural and Community Hospitals, said struggling hospitals often see labor and delivery as an easy target for cuts. But he worries that these short-term closures and limited services will create a ripple effect that will ultimately leave rural hospitals worse off.
“You’ve compounded the problem by forcing people to leave the community when they need care,” he said.
If patients give birth at a hospital in a larger city, he worries they may be less likely to return to the local hospital for future medical care.
“It won’t just be obstetrics,” he said. “They’ll probably end up seeing a pediatrician [at the larger hospital], and the next time they have a sprained ankle, that’s where they’re going.”
Transferring to larger hospitals
Many rural hospitals have already shaved down their services as much as possible, asking nurses to do double duty or transferring patients to larger hospitals for more specialized care.
Fewer than half of the state’s rural hospitals perform surgeries or have specialists such as cardiologists on staff, and many don’t have an intensive care unit. In normal times, it’s enough. But these days, there’s a logjam of patients who are waiting for a higher level of critical care than some of these hospitals can give on a long-term basis.
In the tiny Southeast Texas town of Anahuac, the local hospital is feeling the effects of soaring COVID-19 hospitalizations in Houston, an hour east.
“All of Houston’s medical center [complex of several hospitals] is in code red, meaning everyone is at capacity,” said William Kiefer, CEO of Chambers Health, which runs Anahuac’s hospital, OmniPoint Health. “And so the downstream effect of that is that we have two patients … who require transfer. We’ve had them for days. They’re not going anywhere.”
Rural hospitals say they can usually find beds in larger hospitals for patients who need to give birth, but even that’s become more tenuous as omicron and staffing shortages rage.
Teresa Baker, an OB/GYN with Texas Tech University Health Sciences Center in Amarillo, said she can always tell when there’s been an interruption in service somewhere else in the Panhandle. Suddenly patients are coming from farther away, later in the labor process, and often arriving via ambulance.
“We’re happy to take them,” Baker said. “The hospitals are doing a very selfless thing by shipping those patients, because they know they can’t handle them without the right staffing. The altruism is apparent.”
But hospitals in Amarillo are being walloped by the omicron variant just like everywhere else. During a recent shift, Baker said, seven out of 10 of their laboring patients were positive for COVID-19.
“We just assume everybody’s positive,” she said. “If the baby is born at full term and is healthy, then we can keep the mom and baby together, and the dad, because we can isolate them in the room.”
But many of the babies the hospital delivers have to go to the neonatal intensive care unit for additional care, which becomes much more difficult if the mother has tested positive for COVID-19.
“That’s what makes your heart bleed,” Baker said, “because these moms don’t even get to see their babies or nurse their babies because they’re positive. And it’s just a terrible situation.”
She said for the first time during the pandemic, the hospital has had to figure out issues like how to discharge babies from the NICU to COVID-positive parents.
“I said, what are they going to do, just meet her at the back door with her baby?” she recalls asking the nurse. “Because she can’t come into the hospital unless she absolutely needs to.”
Vaccine misinformation impacts staff, patients
Hospitals around the state are also contending with vaccine hesitancy among staff and patients. That’s just another challenge that’s hitting rural hospitals harder than better-resourced urban facilities.
For a time, Liedtke worried the labor and delivery unit at Rolling Plains Memorial might have to shut down, thanks to a federal vaccine mandate for health care workers that is tied up in the courts.
“To be very clear, I would love to see everyone vaccinated,” she said. “But from a staffing perspective, we were probably going to lose half of our [obstetrics] nurses.”
Other hospitals report similar concerns, saying they’re aware of large percentages of their nurses and hospital staff who would resign if they were required to get a vaccine.
OB/GYN doctors and nurses are also struggling to communicate vaccine information to their pregnant patients, many of whom are wary about a perceived lack of information about the effects of the vaccine on pregnancies.
“It’s so emotional for these moms, and I know they’re trying to make the best decision they can for their babies,” said Baker. “We just have to meet them where they are and just keep revisiting it.”
Baker said she tries to remind patients that the risks associated with getting very sick from COVID-19 outweigh any potential risks from the vaccine.
Holly Dunn, a maternal fetal medicine specialist in Abilene, has seen an uptick in patients needing specialized care because they develop COVID-19 symptoms during pregnancy.
“It’s more common now for my patients to have COVID or have had COVID than not,” she said.
She said it’s her unvaccinated patients who are developing serious pregnancy complications and fetal development issues, and even experiencing stillbirths. She’s implored her patients to get vaccinated for themselves and their children, and tells them about her own experience: She recently had a healthy baby after getting vaccinated.
“So I practice what I preach,” she said. “That gives me some street cred with my patients. If we can convince even one patient, it’s a victory.”
In honor of National Nurses Week (May 6-12, 2018), our Nurses of the Week are Ana Verzone and Jackie Baer, two nurse practitioners who have dedicated their careers to caring for the neglected and underserved populations in America’s rural regions.
According to The National Rural Health Association (NRHA), the US is facing a major rural health care crisis, with nearly one third of the country’s rural hospitals having closed or at serious risk of closure. This leaves rural populations at risk, often putting the lives of the poor, elderly, and chronically ill in jeopardy.
Both Verzone and Baer credit Jonas Philanthropies – an organization devoted to improving our nation’s healthcare through advancing the nursing profession – for the work they do today. As graduates of the Jonas Scholar program, they were awarded scholarships to achieve their Doctor of Nursing Practice (DNP) degrees. Over 1,000 nurses across all 50 states have received funding support from the Jonas Scholar program to further their doctoral education.
To shed light on the current rural health care crisis, we interviewed Verzone and Baer on their thoughts on the issue, and how they are both personally working to provide care to those most in need.
Q+A with Ana Verzone, FNP, CNM, and Jonas Scholar
Ana Verzone is a nursing educator and practitioner who has brought care to the most remote communities across the globe, from Alaskan villages to Nepal, where she conducted her doctoral research on improving communication between rural clinics and emergency rooms. Verzone now teaches future generations of nurses at Frontier Nursing University and the University of Alaska, helping to address the nationwide shortage of nursing faculty and rural primary care providers.
Tell us about your background in nursing.
I love to travel, and before I became a nurse, I was a professional mountaineering guide in Nepal, amongst other places. While passing through a rural village I met two nurse practitioners conducting research on the impact of high altitude on health – they were incredibly inspiring. Knowing I wanted to serve others, I decided to follow their paths and become a nurse. I earned a Master’s in Nursing from the University of California, San Francisco and then worked at San Francisco General Hospital in the emergency department.
I knew continuing my education would empower me to help underserved communities, as well as eventually teach. Thanks to Jonas Philanthropies, an organization that supports doctoral nursing students through its Jonas Scholar program, I was able to pursue my doctorate as a way to give back to the profession I became so passionate about, and to address the shortage of nursing faculty in America. With support from this scholarship, I was able to improve care in remote regions of Nepal, continue my work in remote Alaskan villages, and teach the next generation of future nurses.
Today I work as adjunct faculty at Frontier Nursing University, where I received my Doctor of Nursing Practice (DNP) degree. I have also taught in the University of Alaska’s nursing program.
How did you develop a passion for rural health care?
My mother was a first-generation immigrant, and my father was second-generation. I grew up in a poor environment that exposed me to the great need in underserved communities and inspired me to find ways that I could help improve nursing care in these areas with a sustainable impact. I have worked in private settings, but my heart was always in providing primary care to the less fortunate, because otherwise these communities would have no other options. Rural areas remain the most at risk; they continue to be neglected and there’s still much work to be done.
How are you personally working to combat the rural health care crisis?
I am currently a member of the National Quality Forum’s (NQF) Measure Applications Partnership (MAP) Rural Healthcare Workgroup. This is a multi-stakeholder group that aims to identify appropriate quality measures and measurement gaps relevant to vulnerable individuals in rural areas, and provide recommendations regarding the alignment and coordination efforts of measurement in the rural population. This Workgroup will ensure the perspectives of rural residents and providers—those who are most affected and most knowledgeable about rural measurement challenges and solutions—have adequate representation on MAP.This group will provide recommendations to the federal government for Medicare/CMS’s measurement standards.
Of note: NQF is the only consensus-based healthcare organization in the nation as defined by the Office of Management and Budget. This status allows the federal government to rely on NQF-defined measures or healthcare practices as the best, evidence-based approaches to improving care. The federal government, states, and private sector organizations use NQF’s endorsed measures, which must meet rigorous criteria, to evaluate performance and share information with patients and their families.
My doctoral project focused on improving emergency transports from rural outreach clinics to large referral hospitals in Nepal and was very successful. The protocols I initiated during my project are continuing even though my project itself is complete. I remain committed to rural Alaskans, and continue to serve this population. I also make sure to volunteer in rural areas internationally, so I can keep my finger on the pulse of these issues on a global level. I travel with my family when I do this, since it’s important to me that my daughter also grows up exposed to these issues. My husband is a physician assistant, so he can also actively participate in these trips on the healthcare side as well.
I also hope to improve the quality of healthcare delivered in rural areas by committing to train the next generation of advanced-practice nurses to excel in rural settings. This is important to me especially as a Jonas Scholar, as Jonas Philanthropies empowers nurses to take leadership and faculty roles, to ultimately advance the nursing profession and improve care for our nation’s most vulnerable citizens. Frontier Nursing University, where I currently work, is committed to training advanced-practice nurses that want to serve rural populations, and my work at the University of Alaska supported training students in the specific needs of rural Alaskan regions. Rural areas often require a practitioner to have a wider breadth of skills (primary care practitioners in particular) and have fewer resources available. There are challenges such as geographic isolation or small practice size, limited time, staff, and infrastructure for internal quality improvement efforts. Advanced-practice nurses are a critical part of the solution for these issues.
Q+A with Jackie Baer, APRN, DNP, FNP-BC, and Jonas Scholar
Jackie Baer is a nurse practitioner who runs a free clinic in rural South Carolina, serving 3,000 uninsured patients per year. After witnessing the similarities in healthcare conditions for the poor in rural South Carolina compared to mission camps she served in Venezuela, Baer decided to leave her work in the privatized healthcare sector to serve the rural communities who need it most.
Tell us about your background in nursing.
I began my nursing career in 1993, and after earning my Nurse Practitioner degree in 1998, I was still called to continue my higher education in nursing. With help from Jonas Philanthropies’ Jonas Scholar program, an organization that seeks to advance the nursing profession through the higher education of leaders in the field, I earned my Doctorate in Nursing Practice (DNP) degree at the University of South Carolina. The Jonas Scholar program took a big financial burden off my doctorate education, allowing me to grow as a nurse and connect with a network of nurse leaders that I wouldn’t have had otherwise.
Throughout my career, I’ve worked in many different arenas: ER, research nurse, home-health, rehab, and even a city jail. The different settings have helped me develop a passion for primary care and preventative medicine. In 2003 I started the first rural health clinic in Johns Island, South Carolina—a very destitute and underserved community. My clinic provides primary care to many in my community, keeping open late into the evening and providing weekend hours to accommodate the working poor.
How did you develop a passion for rural health care?
In early 2000 I was a single mother and still relatively early in my nursing career. I took a mission trip to Venezuela and was so inspired by the patients who could maintain health and happiness even with a few resources. When I returned to the US, I stumbled upon Johns Island by accident; I got lost while traveling the Sea Islands of South Carolina and came upon the island and its federally qualified healthcare clinic serving the poor. I stopped by to ask for directions, but as fate would have it, I was inspired by the clinic’s work with the local community and began working there shortly after.When I moved to Johns Island and eventually opened the first rural health clinic in the county, I immediately recognized there were similarities to Venezuelan migrant camps and rural communities in South Carolina. Having spent part of my career working in private care, it was heartbreaking to see a great disconnect between how private patients and patients in poor, rural communities are treated. I believe each patient should be given the same care, which is what drives me to continue my work at my clinic today.
Being a nurse in rural healthcare is so much more than providing care—it’s about being an advocate for my patients. I’m helping people who are in great need, and recognizing not everyone has a roof over their heads. That’s why I chose to be a nurse, not a doctor. It’s not just about writing a prescription or providing an operation, it’s more about listening and providing care. Nurses are taught to care for the heart, mind, and the soul. I try to write few prescriptions and instead focus on life skills versus pills. Looking back, I feel that I have not only impacted my patients but improved the health care of families with early diagnosis and intervention. My doctorate thesis was on weight loss in obese African American women and it continues to be a great success for the community I serve.
How are you personally working to combat the rural health care crisis?
At my clinic, we see around 3,000 patients a year who would otherwise not have primary care options. I feel a very strong connection to my community and am happy to provide a service to the poor. I am blessed to have a 73-year-old supervising physician at the clinic. But if she leaves or heaven forbid something happens to her, my clinic closes! In fact, one physician wanted to charge me $1,000 per month to supervise me in giving medically assisted treatment to patients. The red-tape and financial burden of these agreements continue to overwhelm me.
Health policy change is critical. In South Carolina, I continue to struggle with “agreements” due to outdated laws. Winston Churchill said, “History has a lot to teach and we are doomed if we fail to learn from it.” The National Council of the State Board of Nursing conducted a study in 2018 and found that states with “full practice” authority—the ability for advanced practice registered nurses (APRNs) to work to the full extent of their education—have better outcomes, save taxpayers money, and provide increased care access to rural communities. As doctors continue to leave our rural communities, the opportunity for APRNs is great, but the obstacles in the scope of practice limit success. As a nurse practitioner in rural South Carolina, I work day-by-day under these “agreements,” but could literally be gone tomorrow. Sadly, the injustice in healthcare continues for those that are poor and underserved.
As a highly trusted profession, nursing needs a mammoth legal presence in the state legislature to make sure laws are simple and clear. With fifty years of conclusive data, nursing will win but only if we have a team of lawyers advocating on our behalf. I believe that if “full practice” has improved outcomes for our Veterans, why not for rural America?
