Connected Rural Maternal Care, Closer to Home

00:00:02:28 - 00:00:25:19
Blake McLaughlin, D.O.
With an oasis, typically its water that comes from an aquifer, that is from mountain regions or other regions far, far away. We know that the challenges that our rural hospitals face and providing perinatal services, they're not isolated and they can't be cut off from their water source.

00:00:25:21 - 00:00:59:02
Julia Resnick
That was Dr. Blake McLaughlin, senior medical director of women's health services at Banner Health. His words capture something fundamental about rural maternal care. No hospital exists in isolation. Welcome Back to Frontiers, a podcast series from the American Hospital Association. I'm your host, Julia Resnick. Today, we're exploring the role larger health systems in tertiary medical centers can play in helping rural hospitals continue to provide maternal care and what it takes to make those partnerships work.

00:00:59:04 - 00:01:23:00
Julia Resnick
Emily Brayton is a perinatal outreach nurse at Dartmouth Health in New Hampshire. She also serves as director of operations for the Northern New England Perinatal Quality Improvement Network. Dartmouth Health's connected care partners with health care providers and facilities throughout northern New England, giving them access to the expertise of an academic medical center, regardless of whether they are part of the same health system.

00:01:23:02 - 00:02:02:00
Emily Brayton, R.N.
I think it's really important for systems to have an understanding of the integral role that inpatient obstetric services really serves for their whole entire hospital and their communities is one of those things that we're seeing across the country. New Hampshire experienced closures. It just really changes the communities and maybe who's coming into those communities. I can understand the concerns about settling in a rural place that maybe you have to go far for OB services.

00:02:02:01 - 00:02:23:02
Emily Brayton, R.N.
The strain that that puts on the local emergency departments and the local EMS crews are very, very hard. So I think really focusing on how to sustain inpatient OB services should be the job of every single health care system.

00:02:23:04 - 00:02:51:07
Julia Resnick
When a rural hospital loses inpatient obstetric services, the impact ripples into communities and nearby hospitals. So, if sustaining maternal care is a shared responsibility, what does that responsibility look like for large health systems? At Banner Health, Dr. Blake McLaughlin describes it as starting with a commitment to the communities the system serves and then using the resources of the health system to strengthen care across the entire network.

00:02:51:09 - 00:03:10:13
Blake McLaughlin, D.O.
One of the things that we do is we start from a heart posture, an attitude of care, of love. That is really what drives the work that we do, not fear. And so when we approach things with a scarcity mentality, with a fear mentality, really we're kind of starting on our heels and not from the best perspective.

00:03:10:14 - 00:03:37:08
Blake McLaughlin, D.O.
So our attitude moving into this work is we have a commitment. What we think about too is how do we leverage the benefits of the massive health care system that has a singular priority on safe moms, healthy babies to serve and resource these communities? There is this virtuous cycle that it creates, and it serves and it resources and elevates, really the quality of care,

00:03:37:09 - 00:03:42:19
Blake McLaughlin, D.O.
the standard of care, the entire culture within the whole health care system.

00:03:42:21 - 00:04:14:01
Julia Resnick
As we talked about in the previous episodes, distance can make access to specialty care a challenge for rural residents. But patients don't always have to travel to access specialized expertise. Sometimes the care can be brought to them. South Dakota based Avera Health has been doing this across the Upper Midwest for more than a decade. The system serves communities across a vast rural footprint where long travel distances, harsh winters, and limited access to specialty care are part of the reality for caring for mothers and babies.

00:04:14:03 - 00:04:24:13
Julia Resnick
Dr. Kimberly McKay, an OBGYN and medical research director for Avera Research Institute, says those geographic challenges are compounded by the needs of the communities themselves.

00:04:24:15 - 00:05:00:06
Kimberlee McKay M.D.
The challenge is really about geography, yes. Winter, yes. But also the further you get away from your urban center, you have your increased risk of chronic disease. Of social determinants of health like transportation, housing, food insecurities. You know, when you've got people who live in rural areas, who tend to have more chronic health needs within, especially in the setting of pregnancy, we're always trying to think of ways of how do we push out specialty services so we can keep folks local.

00:05:00:07 - 00:05:27:25
Julia Resnick
For Avera, the answer has been to push specialty expertise out into communities and keep patients local whenever it's safe and appropriate to do so. And it's technology that makes that possible. The work began more than a decade ago, with ultrasound. Using telemedicine to connect scans performed in rural communities with maternal fetal medicine specialists who could interpret that remotely. Today, Avera uses telehealth to bring specialists into rural communities virtually,

00:05:27:26 - 00:05:45:04
Julia Resnick
remote monitoring to stay connected with patients at home, and virtual consultations to give local clinicians another set of eyes when they need them. And there's a really important distinction here that technology isn't replacing local care, it's extending it.

00:05:45:07 - 00:05:52:27
Julia Resnick
In the Mountain West, Banner Health is also using technology to support local providers around the clock. Here's Dr. McLaughlin again.

00:05:53:00 - 00:06:17:14
Blake McLaughlin, D.O.
We have on call 24 over seven 365 OBGYN hospitalists. So those family medicine OB physicians in those rural hospitals, they can get any time a telehealth consult from those OBGYN hospital labor and delivery specialists. Sometimes that will just be a review of the medical record. Sometimes it will be a review of the fetal heart rate tracing. But we can actually provide the service where via tele cart

00:06:17:14 - 00:06:27:26
Blake McLaughlin, D.O.
so it really dissolves those geographic barriers and allows us to continue to keep folks in their community when it's safe and appropriate to do so.

00:06:27:28 - 00:06:50:19
Julia Resnick
Technology brings that second set of eyes into the room, without taking the local clinician or the local hospital out of the equation. The technology can only extend care if there's someone on the ground to deliver it. And in rural communities, that clinician may not always be an obstetrician. That's why Emily Brayton from Dartmouth Health describes rural obstetrics as a team sport.

00:06:50:21 - 00:07:15:15
Emily Brayton, R.N.
I fully believe that obstetrics is a team based sport, and kind of nobody really wants to be making choices fully on their own. But when you're the one obstetrician or midwife who's on, when you're one of two nurses and your other nurse is busy in another room, how nice would it be to pick up the iPad and initialize tele-OB?

00:07:15:18 - 00:07:28:20
Julia Resnick
Banner health has found another way to strengthen that connection, giving clinicians a shared framework for making decisions. And one morning in Wyoming, Dr. McLaughlin saw what that could mean in practice.

00:07:28:22 - 00:07:46:04
Blake McLaughlin, D.O.
They actually have a patient with a category two tracing. And they want to convene a virtual fetal safety team. Would you be willing to help? And I said absolutely. So went out to the desk and sat there with our nurses in Casper, Wyoming Medical Center. And virtually we connected with our team at Worland, and we reviewed the patient's tracing.

00:07:46:04 - 00:08:05:09
Blake McLaughlin, D.O.
We reviewed the algorithm, and according to the algorithm, the recommendation was to counsel the patient and proceed with a caesarian delivery. So we were able to support the team in doing that. They counseled the patient. They had an uncomplicated C-section. We had a healthy Banner baby girl after hours of eight and nine, and mom was so thankful and grateful that we intervened.

00:08:05:09 - 00:08:22:08
Blake McLaughlin, D.O.
The team felt so grateful that we were able to provide that support. So that's the real life stuff that's making a difference, that are keeping folks connected and really raising the bar in terms of quality, safety and the outcomes that we're looking for.

00:08:22:10 - 00:08:35:01
Julia Resnick
But there's another piece to this equation: the people who are there when the technology isn't enough. Dr. McKay from Avera sees that as an essential part of extending maternal care in rural communities.

00:08:35:03 - 00:09:01:28
Kimberlee McKay M.D.
So the technology to the patient, yes, is very important. But just as important is enabling the care teams in the small, the tiny towns. So we've been working with these small sites on not just simulation, but saying, what do you have in your house to be able to take care of pregnancies. So how do you sort of like figure out when you actually need the patient to come in for care or be seen in person?

00:09:02:01 - 00:09:22:27
Julia Resnick
The goal isn't for every hospital to provide every level of maternal care. It's for every team to know what they can safely manage, when they need more support, and how to reach it quickly. Years ago, Dr. Mackay got one of those calls. She was at her son's school conference when an OBGYN colleague from a small Minnesota hospital reached out for help.

00:09:23:03 - 00:09:34:06
Julia Resnick
A young patient had experienced a severe postpartum hemorrhage after delivery and the hospital had run out of blood. The physician caring for her needed help immediately.

00:09:34:08 - 00:09:54:09
Kimberlee McKay M.D.
You know, we face timed into the O.R., she's like, I don't know what to do. So I'm at my son's conference in the hallway of the elementary school, like, okay, like, yep, I'm going to find somebody to connect the dots with. And we got her evacuated. And, you know, just after a few phone calls because, again, the culture is just say yes.

00:09:54:12 - 00:10:16:09
Julia Resnick
For Dr. McKay, that experience helped shape Avera's work to strengthen transfer processes and build more formal support systems around maternal care. And when those types of connections extend beyond individual hospitals and providers, they can become something even more powerful - a regional system of care.

00:10:16:12 - 00:10:31:02
Julia Resnick
At Dartmouth Health, perinatal outreach teams work with hospitals throughout northern New England, including hospitals outside the health system. And that collaboration doesn't end when a patient is transferred. The transfer itself becomes an opportunity to learn.

00:10:31:04 - 00:10:55:00
Emily Brayton, R.N.
We provide debriefs to teams that send neonatal patients to us to kind of talk through and walk through the patient's care while they were at their home hospital, but then also give that follow up of what happened here. We also work really hard on what we call transport conferences, which is where we sit down with our referring hospital teams.

00:10:55:01 - 00:11:07:19
Emily Brayton, R.N.
It's a collaborative approach with both our OB clinicians and our neonatology friends, and really talking about the whole care of the patient.

00:11:07:21 - 00:11:32:08
Julia Resnick
A transfer can be the end of one patient's episode of care, but for the clinicians involved, it can also be the beginning of a conversation. And when hospitals across the region are doing that together, those lessons become shared knowledge. Banner Health has built that kind of peer to peer learning into its rural network through the Rural Whisk Consortium, where nurse and physician leaders come together regularly to share what they're seeing on the ground.

00:11:32:15 - 00:11:35:19
Julia Resnick
Here's Dr. McLaughlin.

00:11:35:21 - 00:11:57:22
Blake McLaughlin, D.O.
We meet together virtually. We talk about best practices. We share and have potluck style about, hey, these are challenges we're facing, these are opportunities. Here's how we're solving for this problem. What do you guys think about that? And it is a tremendously valuable opportunity to really share that one team experience virtually. And so we're proud of that as well to keep folks connected.

00:11:57:24 - 00:12:22:16
Blake McLaughlin, D.O.
It's central to our DNA. It's the core of who we are. And so we want to make sure that that doesn't just end when, you know, we've transitioned from urban metro academic centers and folks out in the rural hospitals are just sort of fringe and out there. Even though we're geographically maybe located across large volumes of space and many miles, we want to make sure that there's one heart and one mind.

00:12:22:19 - 00:12:42:19
Julia Resnick
The value of the network isn't just what any one hospital can provide. It's what becomes possible when they learn together. At Dartmouth Health, regional coalitions bring hospitals and community partners together around the needs of the families they serve. Emily Brayton describes how those coalitions reach far beyond the walls of individual birthing hospitals.

00:12:42:21 - 00:13:11:04
Emily Brayton, R.N.
It really does take a village to raise a child or children or to have a family. And we know that. And so one of the ways that we're broadening the reach from outside of the hospital and leveraging our rural communities and making sure that everyone has what they need is through our regional coalitions. There are 11 of them that are centered around birthing hospitals.

00:13:11:04 - 00:13:42:02
Emily Brayton, R.N.
So if you're doing the math, we have 15 birthing hospitals, but only 11 regional coalitions. And that's because we have a couple hospitals that are close together in drive time. So we're really centering the coalitions around those hospitals, but extending the reach far beyond those hospitals and really getting the support of the community to understand what do families need in order to survive and thrive.

00:13:42:03 - 00:13:46:16
Emily Brayton, R.N.
Right? We don't want people just surviving. We want people thriving.

00:13:46:19 - 00:14:01:14
Julia Resnick
The goal goes beyond connecting rural hospitals to a tertiary medical center. It's about building a regional network around the needs of families, one that can draw on the strengths of hospitals, clinicians and communities.

00:14:01:16 - 00:14:15:01
Julia Resnick
The infrastructure may be technology protocols and transfer pathways, but what makes those systems work is the relationships between the people on both ends. Here's Dr. McKay from Avera Health and Emily Brayton from Dartmouth Health.

00:14:15:03 - 00:14:26:00
Kimberlee McKay M.D.
Technology doesn't foster the relationship. The culture fosters the relationship, which is, if you call me, I'm going to answer and I'm going to try to answer your question to the best of my ability.

00:14:26:02 - 00:15:02:03
Emily Brayton, R.N.
Relationships drive your ability to be productive. And so it's really about getting to know each other, getting to know the hospitals. We find that people are more willing to reach out to us and say, like, hey, we're kind of struggling with this thing. What do you guys think? Having lots of relationships outside of our referral teams really allows us to draw on that vast knowledge and expertise that's in our region, allows us to just be stronger by working collaboratively.

00:15:02:06 - 00:15:32:28
Julia Resnick
Providing maternal care in rural communities isn't easy. It takes grit. It takes commitment, and it takes a deep love for your patients in your community. But it can be isolating, and it doesn't have to be. And perhaps that's what makes Dr. McLaughlin's oasis metaphor so powerful. An oasis may appear to stand alone, but beneath the surface it's connected to something much larger a source of water far beyond what you can see.

00:15:33:01 - 00:16:04:03
Julia Resnick
And that has been the undercurrent for this entire series. Rural hospitals can thrive when they are connected, and so can families in rural America. Thank you for joining us for the special podcast series Frontiers. I've been your host, Julia Resnick. Visit the American Hospital Association's website to explore more stories from rural hospitals and health systems across the country, and discover how they are finding new ways to strengthen maternal care and keep it close to home.

00:16:04:06 - 00:16:22:15
Julia Resnick
This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers or staff.