Rural Health and Health Equity with Tim Putnam

I think it's more than getting people to trust the healthcare system. It's getting every group to be the healthcare system and be represented in it. I think that'll move us farther ahead than what we realize.

Welcome to a virtual view where we talk about tele-health healthcare and everything in between. Our guest today is Dr. Tim Putnam who has served as the CEO of a rural hospital in Indiana, and most recently on the COVID-19 equity task force. Today we will be speaking with tim about health equity and rural healthcare

So Tim, just thank you so much for joining a virtual view, and we're just looking forward to have the opportunity to just pick your brain and just hear about your experiences in rural healthcare as well with telehealth. And so just for some of our audience members who maybe aren't familiar with you, or maybe are hearing from you for the first time, why don't you tell us a little bit about your background in, he.

with you or maybe are hearing from you for the first time. Why don't you tell us a little bit about your background? Well, thank you. I appreciate the opportunity to be here and look forward to the discussion. My background's a little bit different. Grew up in a very small town outta high school right after star wars came out. I ended up getting a degree in lasers and optics because it was just exceedingly cool and was lucky enough to work with a father of laser medicine, Leon Goldman. and laser research and development. And once I got a chance to work in healthcare I. Found the field rewarding was excited about working every day. Then that led to, research and development led to leading a department, leading a division. Eventually you start to think you can run the show better than the people in charge. So I applied for CEO positions with have 20 years background as a hospital CEO, but in rural hospitals came back to my roots where I really Really enjoyed working with people and being in small towns. A little bit of my background and maybe some things, people that know me don't know about me.

Yeah. Thank you, Tim. It's it. Interesting to see just your career progression as you said started in a very different spot and then moving more into kind of, the healthcare administration field with that. Working with hospitals and rural communities has its own sets of, very rewarding, but also very challenging pieces of that. So can you tell us just a little bit about your experience in just working with a hospital and a rural community?

Yeah. If you do healthcare leadership and rural communities you become. so ingrained in the community, you start to care about the community and the people so much that every patient that comes through the ER, that's scared that needs your help really matters to you and you become devoted to their outcome. Every conversation you have on the street is as someone at the hospital and in my job, I always wanted. The community to be proud of the work. The hospital did that everybody that worked there to be proud of it, wear the t-shirt and really realize we're making a difference for people we love and people we know and people we care about. I had the pleasure of training a few years ago to become an EMT and ran 9 1 1 for several years, you get to see people in their homes and you you get a chance to really make a difference for them and get. Personal touch and there just isn't anything like it. My peers that are professionals in urban areas make a big difference in people's lives and they do some things we can't do in small communities, but they don't know the people that come through the door on a regular basis. It's just unique in the world of healthcare and unique in career choices in general.

Yeah, absolutely. You get the benefit of. Living and working in the place that you're providing care and just being able to be a part of a close knit C.

a close knit community.

Cuz you have opportunities to really rub shoulders with other people that are there which to your point, is unique. And that can be both a blessing and a challenge too, cuz you know, people are coming to a hospital to receive healthcare. So you know, those are people that, that are going there to receive care for whatever they're going through. And so that's, there, those are some huge things that are a blessing, but also some difficult parts about working specifically in that context.

It is hard. You ha all of our patients are mortal. There's no way we can save everyone's life and extend their lives to be 150 years old. And everyone that passes away at our hospital or after they receive care at our facility, you sit there and wonder what could we have done different? What could we have done better? And it drives you. It motivates you. But it also, is a real challenge because it hurts a lot. It's it becomes very personal. And then you take that into picking your kids up from school or going to the grocery store, going to the ballgame. You don't escape. There's no way to get away from it or turn the page. And okay. Now I'm just a dad because as a rural hospital leader in your own hometown, you're never just an anonymous person.

you don't have some of the benefits of the. Living in a bigger place where perhaps, the individuals that you're interacting with that may have multiple sources of care may not be with the hospital that you're directly serving. Or perhaps, don't even know that you are, the CEO of that hospital, cuz there's multiple hospitals in that area. And so yeah, it is hard to, be able to turn things off when you're working in that setting. And so I think. That kind of brings up a question of, during this season, it existed before the pandemic, but the pandemic has only amplified it of, experiencing burnout from healthcare professionals and healthcare administrators. So I guess from your experience, what are some ways that you can help cope and prevent burnout when you're working in a healthcare organization,

what are some ways you kinda helped cope and burnout when you're working in healthcare? with it's always difficult over the last couple of years, it's been particularly challenging. I think one of the things is being able to develop that network of people that you trust, that you can lean on. That are really fighting the same challenges and battles that you're fighting. I always think if you're dealing with a difficult issue you can reach out to people that may have solved it, but the very least someone that's beat their head against the wall, trying to solve the same challenge you're facing. And. Having the network of people you trust that can empathize. That not that many people can empathize with the pressures that come in, rural healthcare leadership and how personal it is. So it's really important. You're not out there alone. There's a lot of people, there's 1300 critical access hospitals and 700 other rural hospitals in the country in, in very small communities. And there's a lot of leaders in those trying to do the right things and make their community healthier. So reach out to those folks. The other pig. I have to go for very long bicycle rights and clear my head and just work hard and, think about nothing other than keeping the bicycle up.

Exactly. Yeah. You need to have a mixture of, things that you enjoy, things that help clear your head. But also having a community of individuals that can empathize or are going through something similar. We talk a lot about opportunities for collective impact and how you can work with other organizations that are maybe experiencing similar issues or going through similar pain points on how you can partner with them. But that's a great point of, you you need those connections you don't want to be operating on an island you really want to be working with other people that are doing similar work or experiencing some of the same problems and, putting your heads together to see how you can, move forward from there.

Yeah. There's an old saying that we have in rural hospital leadership, if you've seen one rural hospital, you've seen one rural hospital, but if a program works. in one area, one rural community in the east coast, west coast on the planes. There's a possibility it can work at another. It will not be the same thing. It will not work the same way. You've got different physicians. You've got different rules and regulations, but that's part of what leadership is to take something that works in one place and then try and modify it to fit your organization and not everything will, but. Every time I go to Indiana rural health association conference, or a national conference or regional education session. I come home with ideas and sometimes they're not implemented. Sometimes they are. But many times the concept of it starts to discussion in the community. It starts discussion in the leadership and with the clinical staff and many times that's what. Yeah, absolutely.

Yeah, absolutely. And at, to your point every community is gonna have their own nuances and things that make them, unique from other communities, but being able to see some of those successes and how you can, modify that to be a success. Even from. My own personal experience, working with the crossroads partnership for telehealth, where we've worked with nine rural hospitals to implement new telehealth programs. Each one's very unique. Their patient population's very unique. Their providers are unique the way their leadership structure looks like. So each one is always gonna have to be we're implementing the same service across all of those hospitals, but there's gonna be nuance amongst all of them to modify it and make it work for them.

That's a really strong point, Cameron, that a lot of times. We, we always hear pediatricians say that children are not small adults. And I think it applies to rural as well. That rural is not small urban what works in an urban area. you can't just downsize it and make it work in rural. You've gotta, you've gotta modify it. It's there's gotta be twists and turns and changes and adaptations. And I think that's one of the things where the franchise model of delivering care, where it's just, let's treat all these rural hospitals the same just doesn't work. You can't optimize the kind of care patients receive just by giving us these tools or technologies.

that's a great point. Rarely within any.

any context

you're always gonna have to adapt it to, whatever's gonna work best for that population or group. And that goes for rural or urban. No urban community is exactly the same as the rest. Indianapolis is maybe different from Chicago. Or Detroit there's significant differences even amongst those urban communities. And so rural is gonna experience, a lot of those same issues that come with that. And I wanted to ask when it comes to rural and some of your experience with that there are particular issues that rural communities face that are unique when it comes to the social determinants of health that they face. As far as barriers to health equity. And so what would you say is, an advice to healthcare organizations on how they can begin to work towards health equity in their patient populations. And maybe before that, actually why should you work towards health equity?

Let me give you a little background. I probably should have added this in my introduction, but over the past year or so, I've been lucky to be named by president Biden to the white house. COVID 19 health equity task force. A group of people we've been working on. We've seen a lot of disparities in health, specifically tied to COVID and challenges in delivery of healthcare. So I've been immersed in this topic quite a bit over the last year, and we've seen tremendous inequities. We've seen a lot of, haves and have nots to quote the old George Orwell phrase everyone's equal some more equal than others. So the challenge is. tied a lot to what you're saying on social determinants of health. Sometimes it's access to acute care who can get to cardiac surgery, who can get to stroke care rapidly, who can see an endocrinologist and who can't and our rural areas struggle with that access to acute care. Every endocrinologist is 150 miles away. And how do you get the care that you need? The other aspect. It's tied to the social determinants of health. A lot of rural communities have become food deserts. The small town grocery store has disappeared, and now it's replaced by a convenient store where you can buy everything in a. In a package or off the roller grill. And we don't, how far you live from fruits and vegetables and transportation is a challenge. We have no public transport system, so you have to have your own vehicle. And some people can't drive. Some people don't have their own vehicle, so it creates this real issue. And that ties to education and everything else. I, I think rural. organizations. And I specifically mean rural hospitals are in a position where they're delivering acute care, but they're responsible for their health of their communities. So I see many of them getting stronger in the social determinants. What can we do to prevent diabetes? From progressing as opposed to treating it when it gets vastly out of control and having those discussions, community needs assessments are bringing up issues like mental health and behavioral health, where just 10, 15 years ago, rural hospitals turned their back on those and said, no, we're about pneumonia and broken bones. But now just to really improve the health of a patient, you've got to address the social determinants of health. And you've got to address the behavioral, mental health component.

a great point. And one of the things that kind of sticks out with what you just shared there is. Really having this approach of, we want to be able to, preemptively connect patients to these different care modalities before, it becomes a significant concern or it gets worse. So using to the example, so with stroke especially in rural communities where access to our neurologist may be limited being able to have. Telehealth consultation to be able to bring some of those, that specialty knowledge in that community. Can't be a, for something that is that severe in nature, being able to have access to that care in a quick and timely manner can make a huge difference for a patient.

I do think it is that access point of, when someone's having an acute stroke bringing a neurologist in to that organization 24 hours a day really means a lot, but also starting to get the community to think about. How many strokes are we having? How many people are dying of strokes? What could we do to prevent it? I think when you look at a rural facility, the chief of staff who sits on the board or part of the leadership is more likely to be a family physician than a cardiovascular surgeon. And the concept is how to keep my patients healthier, how to keep them from going down that road. So I think rural hospitals have really been leaders. In this we've seen some really good successes. I've worked with ACOs and on the transition from volume to value and the farther you move down the line, the sooner you can get that, I, the old saying of, improving your diet and, eat your food like medicine, or later in life, you'll eat medicine like food. We want to be able to prevent the disease. And I think as you focus on your mission in rural communities, how do you improve the health of the community? You cannot ignore that. Absolutely. Yeah. That prevention piece is gonna be a huge part of it.

Being able to. Some of these partnerships, which may mean, working outside of the, typical hospital setting. So working with, local churches, food banks, all these other organizations that may be able to help, connect your patients to some of these resources that maybe you can't provide as a healthcare professional or organization. But you can help connect patients or facilitate some of those connections to your point. Help prevent some of those issues where they would end up coming to need to receive care.

Yeah. And you're right. That is, that's one thing in a small town. We don't have. many, any of the resources that urban facilities do, but we work together. You look at the local physicians, the local healthcare leaders they are not very far removed from the ministers or from the mayor or from the public health department or local EMS. We all see each other, we all know each other. We can solve the problems. It's one thing that we can do it and do it much more quickly than the cumbersome larger organizations can.

absolutely. And so with that point when, and staying on the health equity topic. What benefits do you feel like technology like telehealth has in increasing health equity for populations?

what I've seen in a lot of rural areas is. patients can't physically get to where they get the care that they need. If you think about the patient that the young mom who needs a prenatal visit the logistics of getting into some urban area, that's 70 miles away for a 9:00 AM appointment and a place that they never go. Transportation that's unreliable. It just becomes very difficult to accomplish. If we can do things and a stroke is the perfect example. I'm so proud of what we've done in rural areas with stroke programs and telestroke networks to be able to get care of patients any, but we haven't gone to the point of getting that move to prenatal care or diabetes visits or endocrinology or things that don't require that patient to physically come to a physician's office. There's a lot we can do through video, through connections, through shared information that they don't have to physically travel. And if we can avoid that, then that mom gets more prenatal care, better prenatal care than they could have. Without it, they may not get any at all. So I think it's tapping into technology. Now you have to realize this is a guy that got excited about. Going and studying lasers when he was a teenager. So I'm pretty exposed to like technology and use it to the best of our ability to improve the lives we live. So I'm for using that. A lot of people are resistant to it, and I think that's one thing leaders need to realize is the physician will feel more comfortable that patient's in front of them almost always. So you've gotta get through that. You gotta get over that. And how do we make that happen now that there's always resistance from the physicians, the providers. And you're gonna have to anticipate that, but sometimes they can really see the value of it. Then you have another barrier with regard to payment comfort with the patients and the technology are typically easy to clear the payment method and the providers being comfortable. And you have to empathize with the provider's issue too. They're saying. I'm responsible for this patient. And if I'm seeing them on video or not getting a clear message, I might miss something and that's not a responsibility I'm comfortable with. See, we really need to empathize with them. From that perspective, some will be very comfortable with it and some will not be comfortable at all. We've seen that over the last several years, several people are really comfortable with video meetings. Others are like, as soon as I can end these things, I will, I have no desire to ever be on a video call the rest of my life.

Those are some of the things that in one of our recent podcasts, we had actually talked with someone and he was mentioning during the pandemic, we are having the largest use cases of lots of different service lines and different applications for telehealth that we've never had before. Some very clear examples of that is, occupational therapists and physical therapists. We've really never had many opportunities to see what it's like to deliver telehealth via these options. And.

And so

We're being able to try out all of these different service lines and different services. Maybe that we didn't get the chance to prior because of, reimbursement barriers or other policy and restrictions that just limited. The ability to be able to do that. What will be really interesting? With what you said is, I think we're gonna see people that will be in a variety of different camps because now a lot of patients and providers have been able to try telehealth for the first time. It's pretty unavoidable. If you're a provider. You provided telehealth at some point over the past two years, if you're a patient, maybe, perhaps you didn't engage with it. But still lots of patients still needed to engage in telehealth at some point over the past two years. And so I think we'll see some of these camps of, maybe some that were like, I would never want to do this and they do it for the first time and really love it. Or maybe some that are like, I really wanna do this. Try. It, they don't like it as much, but we're getting this first taste of, organizations really getting to try it on a large scale, understand for themselves versus, just making assumptions of what it would look like or how do you do it. So that's one huge benefit to your point of, regardless of what can't people fall into, they've at least have been able to try it in the past few years.

I think we've proven that it can work. It's what I look forward to in the future is now that we've learned all this and how, what works, what doesn't the big concern from the payment side is the potential for abuse. One physician just set on the screen and see 250 patients in a day and, just bill for all that and not provide the level of care. And I think we'll get over that. It'll take a little bit to get over that, but I think, we've learned some hybrid programs work. I'm familiar with a program where a school nurse has access through telehealth equipment to be able to connect with a physician, to assess the child, is this something really going on? And she's got the capability using the video otoscope and send. Video capabilities on everything we can do. I think sometimes we need to look at hybrid options where a patient goes into an office with a primary care physician and sees a specialist, or goes into an office with a medical assistant that can do basic assessments and draw blood. And then the video and. Conversation happens in a, an evaluation, happens with a physician. I think there's a lot of solutions out there. It's difficult because the payment models don't work for it. But there's a lot of rural communities that are really distant. And you start talking about on islands and long drives down dirt roads to be able to get out. What can we do? There's a lot that's happening. We saw with the. The task force that I worked with on broadband, having broadband access everyone having that and their home is important but also even into small towns, so you can go someplace and get access and that just doesn't exist across the country. So I think there's a lot we've learned and we'll just be piecing it together over the next few years.

Yes, absolutely. And I think it will be, every organization will just have to figure out what works best for them and what works best for their particular patient population. We've already talked about, there's not really a good one size fits all type of approach and telehealth service delivery is really no different. So figuring out what, makes sense and especially in some of these areas that you're talking about that are very low access there. Those may be areas where just getting any sort of access is gonna be better than nothing. And so even if there's something that perhaps in another setting, if it was possible would be conducted in person, at least telehealth is giving the option to be able to provide the care at all. And especially in some of these very more remote rural areas and that's something across the United States. And I think. Communities that are, on mountainside and some of these more difficult places to reach and, broadband is its own issue with that. And so I always have to note that, but I won't dive down that particular rabbit hole at this moment, but but being able to get access to any of that care, if they have literally zero access outside of that is always gonna be preferential.

And that, that leads to that equity standpoint. How can we deliver equitable care or become more equitable in the care we deliver? We saw so much of the people who have and have not The death rate for people that had uncontrolled chronic disease in the pandemic was far higher. So if you had diabetes that was uncontrolled CF, C O P D high blood pressure, uncontrolled obesity and you never had access to care that really created a problem. And your survivability was much lower with COVID and we just have to have a discussion in the country. Is health equity important to us? Does everyone having access to healthcare regardless of how we have to deliver it? Make us a stronger nation. I personally believe it does. I devoted my life to it but I think that's a discussion we really need to have as a nation. Is this important? Can we face a pandemic? Can we face an economic crisis? Can we face a large scale war better? If everyone has access to healthcare and we have more equity in that world.

That's a great question. And that question that you have is the question that drives. Everything. It, it drives policy. It drives, legislation, it drives, what are the services that are offered to patients? That question is a huge question to ask and really does impact the future direction of healthcare outside of telehealth, just in general healthcare. The direction that it would go. That, that very question that you just asked.

Yeah, telehealth has a great, is a great tool to be able to improve health equity. But it's one of the many tools we've gotta have that broader discussion about what do we do? We've got 20% of the population that lives in rural areas and less than 10% of the physicians we don't have enough physicians to go around. And the other thing is that 20% of the people live in 90% of the country. So it's a lot of ground to cover with the few bodies. We've got to do it. What tools concepts we can do to be able to deliver equitable healthcare needs to be part of the discuss.

Absolutely. And so as just a closing point, Tim since we're talking about the health equity piece, is there any kind of, I guess closing thoughts or any advice that you have for individuals who are really looking within their organizations? Whether it be in a healthcare organization or looking more from like a legisla. Standpoint on how they can really be an advocate for health equity in their communities.

I think understanding the situation every rural community is different, so they've got different challenges, but where are the inequities in the community? Is it access to health insurance? We've got several states that have expanded The Medicaid program to be able to cover more people in several states that haven't how's that impacting people in your community and what story needs to be told on that. There's a lot of this of really understanding and opening our eyes. We get a lot of data. CDC produces a tremendous amount of data on the gap between rural and urban and life expectancy, which has expanded tremendously 25 years ago. There was very little gap and now it's nearly two years. What's causing that what's causing that in your community. There's an inequity between rural and urban. There's an inequity between African American, Hispanic, native American and others. And how do we serve that? Unfortunately, it's not a franchise answer. It's individually. Doing that, but I think it's taking community needs assessments, seriously. Understanding the individual challenges. I'm a big advocate for getting the healthcare system to reflect the community. Having more kids that grow up in rural areas become physicians. Become nurses, become therapists, become technicians having more African American, Hispanic individuals, native Americans have a pathway to become healthcare providers. So many times, what young people understand about healthcare is really what they see on Grey's anatomy. And it's not exactly the same. If you have a parent or an aunt or an uncle in healthcare, your ability to get into healthcare is greatly increased because there's a, you understand the reality of it. You, they understand the pathway, but if we've got so few people. In certain demographic groups that are in healthcare and they've got no one to look up to, to be able to understand how they can become the greatest physician in the world. Coming from a rural community when you didn't have an advanced biology or advanced chemistry class that's a challenge and we need to look at how we solve that, how we get more rural kids into healthcare, how we get more African American kids into he. That'll make us stronger. That's the strength of our nation is our diversity. We have not tapped into it in healthcare. Like we. And

That's great, Tim. And yeah, I think, what you said there is great of kind of just summarizing it. Really educating yourself and understanding what the needs of your community are first. So that what resources to really, focus on as well as, finding opportunities to improve representation in the healthcare field of, we want patients to be able to receive care. People who understand their cultural context and to be able to provide culturally competent care to patients. So finding opportunities for, more representation within the healthcare field as a whole and really, to your point, the future of our workforce, making sure that the future of our workforce is diverse and can help meet the needs for a variety of different patients, regardless of their background or upbringing.

Yeah, we saw this was a trust factor. Certain populations, rural being one of them. Other demographic segments did not trust what the healthcare system was telling them during the pandemic. And to a certain extent, you can understand that. Why do I. trust someone who doesn't look or sound like me, that doesn't have the same background. If everyone in my small community came from someplace else to, I really trust them when I'm getting so much conflicting information about this disease. So I think it's more than getting people to trust the healthcare system. It's getting every group to be the healthcare system and be represented in it. I think that'll move us farther ahead than what we realize.

Absolutely Tim. I just wanna thank you so much for your time and just for giving us the opportunity, just to pick your brain and to just dive in a little bit more about your experiences in rural as well as in telehealth and in health equity. So just want to thank you just for coming on our show today and we look forward to future conversations.

I look forward to Cameron. Thank you very much. It's a pleasure being.

Thank you, Tim.

You're welcome.

Thank you for listening to a virtual view. You can find more information about today's episode in the show notes below. If you would like to support our podcast, please rate and review us on your favorite podcast player. Do you have any questions or topics you'd like us to discuss? If so, contact us at info at UMTRC dot org or through the form found in the show notes. Also, we'd like to give a special thanks to our editor. Finally a special thanks to the health resources and service administration. Also known as HERSA. Our podcast series of virtual view is sponsored in part by hearses telehealth resource center program, which is under hers is office of the administrator and the office for the advancement of tele. The content and conclusions of this podcast are those of Cameron hilt of the UMTRC and should not be construed as the official policy of, or the position of nor should any endorsements be inferred by HERSA, HHS, or the U S government. Thanks for listening and have a Great day.