Rural Rivals Team Up to Coordinate Care

In a small North Dakota community, a community health center and a CAH have found a way to work together in what they're calling a patient-centered medical neighborhood.

I've been writing a lot lately about the evolving role of rural providers in this new age of value-based reimbursements.

Health policy think tanks, rural health advocates, state hospital associations, and local providers are trying to find more efficient delivery models that create optimum use of scarce resources for remote populations.

One success story can be found in Beulah, ND, pop. 3,152 or so, located about 77 miles northwest of Bismarck, and whose town motto is "Small town appeal... Big city looks."

For years Coal Country Community Health Center, a federally qualified health center in Beulah, was locked in a struggle with rival Sakakawea Medical Center, a 25-bed critical access hospital in nearby Hazen.

"We were the poster child for competition and conflict," says Darrold Bertsch, CEO of SMC since 2009. "It was most evident in the duplication of primary care and ancillary services. Each of those was done to protect the market and to protect each other's turf. It resulted in a waste of resources and a duplication of services."

The competition proved particularly detrimental for CCCHC, which in 2011 found itself in financial straits and with a leadership vacuum. "The health center reached out to the hospital through the encouragement of the health center's medical director, to see if I might provide some interim leadership to find out what was going on with some of the revenue cycle and cash flow issues, and what we could do to stabilize staff and improve morale," Bertsch says.

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He accepted the job, but not a salary. He is considered a health center employee under a joint administrative services agreement that sells services back to the hospital. That helped assuage local fears that SMC was taking over CCCHC.

The two providers also worked with the Health Services and Resources Administration, which oversees funding for FQHCs, to gain approval of the interim relationship that began formally in March, 2011. HRSA generally frowns upon hospital, municipality, or 501(c)(3) ownership of a FCHC. They make exceptions, however, if the health center has its own independent board of directors.  

After familiarizing himself with the health center's operations, Bertsch says he hired consultants to determine how the goals of the boards of directors for both providers meshed with the reality on the ground and how they could move forward together. "We wanted a fresh, independent set of eyes come in to take a look at our situation and they provided some recommendations, some of which we had already implemented, and others that we implanted afterwards."

"We ended up eliminating some of the duplication in ancillary and primary care between the two organizations," he says. "We placed two reciprocating board members, meaning that there are two board members from the hospital board that sit on the health center board, and vice versa so that there is total transparency with the CEO. And me, as the CEO, I report independently to each board and have responsibility to each board of directors for each organization."

Bertsch says the partnership has avoided conflicts of interest or collusion largely by making patient need a priority. "My point always was that if you put patients' needs to the forefront and you have vision to optimize the programmatic benefits of the critical access hospital program and the federally qualified health center program, the conflicts of interest should not be that prevalent," he says. "That is all fine and dandy to say, but it has truly worked for us here."

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That spirit of cooperation and coordination has spilled over to include other providers to take part in the community needs assessment.

The Patient-centered Neighborhood

"Many times organizations do their community needs assessments because it's a programmatic or IRS requirement," Bertsch says. "We truly took it to the extent that 'let's get all of the local providers, the hospital, the health center, the ambulance provider, the nursing home, public health' and we all came together to do the community health needs assessment. When we had the results of that, we also developed a collaborative strategic plan. And now we have a collaborative community health improvement plan. We have our individual responsibilities as organizations, but we also have the responsibilities of the group as a whole and we meet quarterly to review those goals."

"By working together in what I call the patient-centered medical neighborhood, we know that we are able to provide care in a better, more organized and coordinated way because we are doing care coordination with the clinic and the hospital," he says. "We've also improved the financial position of both organizations. They both have a better bottom line because of our collaboration. We are no longer fighting for the resources in the area. Like all areas, the workforce is limited and the market share is limited, but we are optimizing the programs for the betterment of the patient."

What was once a poster child for harmful competition has evolved into a model for cooperation, and the success has not gone unnoticed.

Last spring the National Rural Health Association took the unusual step of naming the two providers its winner of the Outstanding Rural Health Organization award. "In a healthcare culture where the need for healthcare organizations to collaborate and cooperate is often discussed, this critical access hospital and community health center serving patients in rural North Dakota have combined efforts resulting in a higher quality of care and improved financial gains," NRHA said of the co-winners. "This success story demonstrates what can come from strong leadership, innovation and collaboration."

Guidelines for Future Collaborators
For any providers looking to emulate the Coal Country/Sakakawea collaborative, Bertsch says a few things need to be in place.

"First of all, there needs to be collaborative assessment of the healthcare needs of the area," he says. "All too often I hear independently that the hospital has done their health assessment and the health center has done theirs and they are not sitting at the table doing it together so they learn more about the role each other plays in those needs. Just as importantly, they need to use that information to create a collaborative strategic plan."

He also recommends transparency in the process.

"Granted, not every community will have a shared CEO and it's not the right model for everybody," he says. "It was the right one for this sized community, but what can be in place is transparency in governance. To have that reciprocating governance where the same information is shared with each organization and it helps provide more of a unified vision in that particular community."

While understanding that all healthcare delivery is local, Bertsch says he would not be surprised if more rural providers develop similar cooperative models.

here are more that need to be developed, but sometimes personalities and other reasons get in the way," he says. "As we're all shifting from volume to value, we are going to need to work together. Here, we feel so blessed because of the relationship we have between these two organizations."