An interview by Pamela Jones, RN, MSN, MS, FACHE, EDAC with NIHD member Val Williams AIA, Senior Healthcare Planner Senior Associate at Page.
Pamela Jones, RN, MSN, MS, FACHE, EDAC
Val Williams AIA
First and foremost Val – how do you define rural health?
Rural health can be defined two ways.
Well, the USDA delineates a rural area as anyplace consisting of open countryside with population densities less than 500 people per square mile and places with fewer than 2,500 people. In my home state of Colorado, the State Office of Rural Health defines ‘rural’ as a non metropolitan county with no cities over 50,000 residents.
Secondly, my definition would be areas where people have shared history and give directions by landmarks, they have lived there for many years and the community is close knit. They are at least 30 minutes to an hour away from a healthcare facility and less than 5-10,000 people are nearby. Rural health delivers very personalized care, everyone knows everyone else and you were there when Joey passed away and you brought their family a casserole.
Why is rural health your passion?
I grew up in rural Georgia. When I broke my arm in 2nd grade, my father took me past a hospital to take me to the ‘good hospital’ – another ½ hour of travel. We lost our local primary care doctor while I was in Jr. High School, which means we also lost the quasi-urgent care that you can get from primary care. So, I am familiar with rural healthcare and like having a direct connection with the people I am helping – that is satisfying for me.
People who operate rural health facilities are MacGyver in disguise. They know how to do more with less and have a remarkable creativity streak because of having to make do – they learned from their parents. Generations of healthcare MacGyvers invent some really good ideas on how to solve problems. I call that super resourcefulness.
What are the biggest challenges for rural health?
Rural health facilities face the same challenges as larger urban facilities but the pressure is more intense. They don’t have the volume of patients to meet margins. Lots of Medicaid, uninsured and charity without the private pay volumes.
Many rural health facilities were built in the Hill-Burton era meaning they do not meet ADA; they may contain lead and asbestos; clinical and support rooms are undersized; and many treatment room finishes, ventilation and filtration do not meet code. The 70 year old facilities have crumbling infrastructures but they are kept spotless! They are unable to undertake capital projects as the cost of borrowing money is just too much. The well for philanthropy for 4,000 people / businesses dries up very quickly, they cannot spread the philanthropic load – “those are the same people we asked last time”.
In your interviews with rural health administrators, what keeps them up at night?
How do we provide all of the services that our community needs with all the restrictions that are on us? We need to be a one-stop-shop for the community. It is not just the financials I have talked about but keeping a certain number of births per year, experience and training with that volume to maintain an OB / Delivery service. People want to be able to deliver their babies close to home.
Nursing homes and assisted living facilities are closing at an alarming rate and folks worry they cannot age in their own town. Grandkids not having to travel hours away to see their grandparents - taking them away from their community and continuity – not losing the beginning and end – having a baby and aging. It is absolutely necessary but reimbursement is so limiting. Having to be all things to all people and regulatory does not necessarily work that way.
What information do you wish nurses and designers knew about rural health?
The rules that control large academic teaching facilities are the same for a rural USA 25 bed critical access facility. Legislators need to know this as well! The physical regulatory environment in which I have to design within, FGI Guidelines, is not flexible enough to accommodate patient and staff flow. The same people may cover three or four departments. With a smaller structure it can limit us from finding inventive ways to provide care.
There is a certain ethos to rural health, one may drive a tractor to get to another area rather than a car or they may need larger parking spaces for big trucks. Not everyone wants to live in, or can afford to live in urban areas. There is a political divide between cities and country – we need to make sure everyone has access. Supporting rural communities and making them much more livable – helps cities too.
Knowing where to find healthcare when traveling makes the USA a safe place to travel with the right sources to go to if you need help. When we support rural health we are supporting quality of life for all of America.
How can nurses and designers contribute?
1 - Be creative, exploring opportunities to try things – ‘what if we did it this way?’ Kind of a micro hospital – giving them room to play and come up with some ideas that could even help larger facilities. Whether officially designated so or not, every rural hospital is a safety net hospital.
2 - Discuss that what you are designing is not how you work today, but how you want to work. It is not just a bigger version of what they already have. Let your rural clients know that you are going to push them to look at how to work differently.
3 - Understand that design will include some tough conversations and recognize that you are an ‘outsider’ stepping into their ‘rural world’.
4 - Ensure that they understand that you are not customizing spaces for a particular person but for the role.
5 - Be careful with HIPAA. There is an extra layer of intimacy among the rural patient and caregiver population.
6 - Explain the importance of meeting regulations and why that is important - such as ADA and things like DI water from copper pipes. Help them re-think how to do things that are required by code.
7 - Be thoughtful but ask more questions, use the 5 whys to challenge them - this is a good way to get at what they really need instead of what they think they need based on existing conditions.