Right-sized health care

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Today we're talking with Nancy Dickey, MD, and Bree Watzak, PharmD, two experts at Texas A&M who are helping to address the issue of hospital closures in rural and outlying areas in the United States.

Episode Transcript

Lindsey Hendrix: Hey there. Welcome to The Vantage Point. I’m Lindsey Hendrix. Think for a minute about how you would set up a city or a town. Most likely, you’ll have a school, some type of financial institution, a fire station, a police department, somewhere for people to live. What’s missing? For many people across the nation, a vital part of their small town or city is going away, and it’s something those of us who live in large, urban centers might take for granted. It’s a hospital. This is a huge problem, and it’s impacting millions of Americans. Today we’re talking with Dr. Nancy Dickey and Dr. Bree Watzak, two experts at Texas A&M who are helping to address the issue of hospital closures in rural and outlying areas in the United States. Thank you both for being here.

Nancy Dickey: Absolutely.

Bree Watzak: You’re welcome.

Lindsey Hendrix: Would you please take a moment to introduce yourselves and tell us a little bit about the work that you’re doing at Texas A&M? Dr. Dickey, we’ll start with you.

Nancy Dickey: I’m a family physician by training. I’m the executive director of the A&M Rural and Community Health Institute. The institute is both a service organization. We create programs and projects that will assist small hospitals to meet the reporting and quality guidelines that will keep their hospitals open, and hopefully at a price they can afford. But in the last decade, we have increasingly taken on more of an academic arm as well. So, investigating how we are able to move small towns into 21st century medicine. Medicine is becoming increasingly technological. The professions relating to medicine have become ever more specialized, and so those specialties require a bigger and bigger population in order to have enough patients to take care of. That means Houston has one or two or 10 of everything. But Tiny Town may not be able, certainly can’t afford a vascular surgeon or a neonatologist. So how do we make sure that Tiny Town has access to quality 21st century care in a time when that care increasingly needs a big industrial complex in order to offer the care? So, that’s what we’re doing.

Lindsey Hendrix: All right, and Dr. Watzak, what about you?

Bree Watzak: Yes, I’m a pharmacist by training and I work at the A&M Rural Community Health Institute. I work on several of their contracts, helping rural hospitals in Texas, and in the past four years, worked on our how do we help communities that are struggling to keep their hospital open and to keep health care local, how do we help them? And then, this September, past September 2018, I helped write the HRSA grant, that has funded us to create the Center for Optimizing Rural Health, and that’s where we’re working with hospitals across the nation and their communities to ensure that they have the local health care that they need.

Lindsey Hendrix: So, we’re here to talk about the problem of rural hospitals closing. What are some of the specific challenges that these hospitals are facing that is forcing them to close their doors?

Nancy Dickey: The ultimate force towards closure is virtually always financial. But it’s related to the things I said in my introductory comments. Fifty years ago, 70 years ago, almost everything that someone went to the hospital for could be done just as effectively in a 25 bed local hospital as it could be done in whatever the 70 years ago Texas Medical Center looked like. But in the meantime, we have learned how to replace joints, to transplant virtually every solid organ in the human body, we have found ways to cure many cancers and to treat virtually all cancers. But many of those things require a substantial team. They require somebody to run the heart lung pump. They require a lot of sophisticated different people in the laboratory, and maybe as many as six or eight different specialties in medicine, probably a couple of specialty pharmacists to help keep all those medications straight. So, the day when the family doc and the local pharmacist could take care of the vast majority of what required hospitalization is gone. And so now, if you live in a small town and you get pneumonia, you might stay in that small hospital. But if you get a really massive heart attack, you’re going to get transferred to the big city in the hopes that you can reopen that blood vessel. And so 70, 80, 90 percent of what might have been in that small hospital now moves to the big city. And you don’t have enough people in each small hospital to keep the doors open. So, as Dr. Watzak said, it’s partly about how can we keep the hospital open, but also, which hospitals can we keep open. And at the same time, if you don’t have a big enough population to be able to financially support a hospital, how do we keep access to care locally even if it doesn’t include inpatient care.

Lindsey Hendrix: Mm-hmm. So we’re talking about that primary care physician who can at least see you if you have something that may not require hospitalization or would need a referral up to the bigger hospitals, right? Is that what we’re looking at?

Nancy Dickey: For some communities. But sometimes the community is so small it won’t even support a primary care physician. So, some of the solutions that we’re looking at are in communities small enough that they can not financially support a primary care physician. And that’s almost never one, okay? Physicians today are a little more attuned to their own wellness and they don’t usually want to work 120, 150 hours a week

Lindsey Hendrix: Understandably.

Nancy Dickey: So, they say, you know, there’s got to be at least two of us, or four of us, okay? Well that takes four times the population. So, can we provide some level of primary care, chronic care management, evaluation of which things really need to go someplace else now versus they can wait til the doctor comes on an itinerate calendar once a week. Okay, can we do that with community health workers? Can we do that with a reutilization of your EMTs and paramedics in town? Can we do it with the local pharmacist? These are roles that haven’t traditionally been done by those people but they are possibly roles that would allow us to help people stay near home and at the same time get access to educated assistance in decision making. I really need to go to the nearest urgent care or emergency room or hospital, or I really need to call the helicopter and go all the way to the big hospital. Or I think we can call the doctor, maybe use telemedicine, change some medicines and wait until the doctor actually comes to town next week. So, those are very different care arrangements than what we have traditionally done. But, they may well help small towns keep people healthy and come closer to the standard of health care that Americans come to expect.

Lindsey Hendrix: So, you talked about technology advancing medical care and health care in general, and kind of contributing to the problem because then you have the need to support so many more complex and technologically complex procedures. But how can technology then play into the solution for these rural communities?

Bree Watzak: One of the ways that we’re exploring is through project ECHO, I don’t know if you’ve heard of that, but it seeks to take knowledge from an academic center and elevate the knowledge in a rural community. And so, it was started with hepatitis C, where the physician who started it there was a long, several month wait period for patients to get in. And what he found was those patients from rural areas would make the drive once and then never come back. And so, what he decided to do was replicate his knowledge by using technology, sort of like Skype of Facetime or whatever type video conferencing you’re use to, and he would connect with the rural providers and those rural providers would talk about their patients and ask questions. And over their span of being a cohort, like a year, he mentored them so that their knowledge level grew and then by the end of the year they had all the knowledge that he had and they had a life line if they got stumped on a patient. And so, project ECHO has expanded to different disease states and at The Center for Optimizing Rural Health, we’re going to utilize project ECHO to work with hospitals to help the hospitals. So we’re not necessarily doing a human disease state, more a hospital or health care disease state.

Lindsey Hendrix: That’s awesome.

Nancy Dickey: But you could also, so this is using technology as a consultative process, an education process. I love ECHO’s tag line, and I’ll try to get it right, but it’s taking the knowledge to the patient instead of taking the patient to the knowledge. And in New Mexico or West Texas sometimes those can be a pretty good hike—

Lindsey Hendrix: Right

Nancy Dickey: —and as we were just talking before we started, sometimes on not so good roads. But you can also take the doctor to the patient. So ECHO started because there were too few specialists in this particular area and they recognized that they needed to increase the level of expertise on a relatively new disease for a whole lot of providers so that those providers, doctors, nurse practitioners could give a significant piece of hepatitis C care and not require referring that patient in for consultation for every hepatitis C patient, but rather, only for the most complex hepatitis C patients. That means you can get your hepatitis C care locally, without traveling, and those handful of sub-specialists for hepatitis C no longer had a six to nine month waiting time because you got the simple ones relatively taken care of, and so now if you had a complex case you could get in in a timely fashion and maybe treat the disease before you were dying of the disease. But, in some instances, we have enough specialists, they’re just not out in small town America.

Lindsey Hendrix: Right.

Nancy Dickey: And so, using telemedicine, and it’s not much more complex than Skype or one of the video Facetime that we happen to use. It does require a little more technology because for me to listen to your heartbeat I can’t just put that microphone on your chest, okay? But, we now can do the vast majority of the physical examination, everything except what you feel with your hands. I can see in your ears, I can see in your eyes, I can look in your throat, I can listen to your heart and lungs without being there in the room with you.

Lindsey Hendrix: Wow.

Nancy Dickey: All through technology. So, we’ll be using telemedicine that is bringing the specialists to the small town hospital. So if currently you’re sending 90 percent of what needs to be hospitalized to the big hospital, maybe you can reduce that to 70 percent and the additional 20 percent of people can be effectively, high quality access to care right there in your small hospital because the neurologist or the cardiologist or the endocrinologist can see them on a daily basis in the hospital. There’s some great video of people, go on Google, and you can see what looks kind of like R2D2 coming up to the bedside you know.

Lindsey Hendrix: Oh wow!

Nancy Dickey: And so, it is a way to again, take the expertise to the patient instead of forcing the patient to come to the expertise. I think telemedicine will be a big piece of this and if you think about that at another level, we can take community health care workers, many of whom are high school educated, give them very specific training, certainly not nursing school or medical school or pharmacy school, okay? But when they go and see a patient who has diabetes and they realize that the sugars are out of the range of what’s expected, they can use an iPad or a smartphone for that matter, call into the primary care doctor, and without that patient ever leaving home you’ve taken care of a complication which if ignored three days from now might mean that patient was in serious trouble and racing across highways in an ambulance to hope to get to a higher level of care. So, modern technology is going to be part of the solution and again, we’ll raise the quality of care that’s available in a small town even though that small town will probably never be able to afford to have the -ologist of whatever sort move there and give care there on a daily basis.

Lindsey Hendrix: You talk about community health workers. They probably play quite a big role in education. So there’s plenty of disease states out there that are preventable. How does health education play into the solution?

Nancy Dickey: This kind of goes a little beyond hospital closure discussions, but when you’re having a hospital closure discussion you’re having a community discussion, right? This is not the hospital CEO and CFO, this is the school board and the hospital board and maybe the ministers from the six largest churches. All those people who are the thought leaders and the voices of a community come together to say you can’t close our hospital. So it’s an opportunity to say, “How do we work with you as we transition to whatever right-sized care means for your sized community?” And that almost inevitably turns to “how do we make you a healthier community so that you require fewer transfers to a higher level of care?” And so some of these facilities may actually turn into wellness centers rather than inpatient hospitals. We’ll do your rehab there. We’ll do, oh gee, if you’re doing rehab how about a few hours a week you could also just be doing fitness training. We know if you’re older and you get balance training you’re less likely to fall, less likely to break your hip and therefore, less likely to get shipped off to the big city. The same is true for nutrition education and appropriate use of your medications. So, keeping the community as healthy as the community can be outside the health care system minimizes their need for a formal health care system.

Bree Watzak: Community health workers, when they go into the house and have those home visits, they find some very educational moments to sit down and talk with the patient. I remember one of them telling me about a home visit where they went to a diabetic patient and that patient didn’t have a refrigerator and so the insulin had been, you know, it’s hot in Texas, so their insulin had been above the ideal temperature because there was no air conditioning in the house either, so it wasn’t as effective as it could have been if it had it been maintained at the right temperature. But then also that limited the food that they had. So, they had all the high carb food that didn’t need to be refrigerated, which again, exasperated the blood sugar. So that was a moment for the community health worker to look at the environment and to talk with that person about what is going on with their house and their situation and have very direct and specific education on their disease state and what they needed to do.

Nancy Dickey: But it’s also an opportunity then to get back to that healthy community. So, I don’t know of very many insurance companies that would have gone out and bought that person a small refrigerator, although, you could make a good argument for a private insurance company that a $75 cost for an apartment-size refrigerator might save multiple very expensive hospitalizations.

Lindsey Hendrix: Right

Nancy Dickey: But that community health worker can go to United Way or Salvation Army or whatever the community’s safety net organizations are with the recognition that this isn’t a routine prescription but it might save a whole lot of money. We went to another community—kind of an ahh ha moment, but one that we began to fold into some of our conversations with other communities—and that is how in your community do you know where there might be people having problems? And this community said well, we discovered, we realized—and they had been facing a hospital closure—that people who had trouble paying their utility bill were at great risk of having health issues because if they couldn’t pay the light bill they probably weren’t filling their prescriptions, they probably weren’t seeing their primary care physicians, they probably weren’t getting the laboratory work done that would tell them how they were doing. So as a community, they began to use that as, here’s a high risk population, maybe that’s where we should send the— they didn’t have community health workers, but—that’s where we should send the EMTs to check on these folks or that’s where we should send the community health workers to say your community cares about you, is there anything we can do to help. Fascinating. I would never have thought to say don’t pay your light bill late, you might get a knock on your door from the community health worker.

Lindsey Hendrix: Wow, that’s amazing. So talk a little bit more about The Center for Optimizing Health. Y’all were awarded was it a federal grant? And describe some of the work that you’re doing.

Nancy Dickey: So the center is funded by the Health Services Research Administration, did I get that right? HRSA. And it is an annual grant of $800,000 renewable, non-competitive renewable, meaning if we don’t screw it up we probably get refunded.

Bree Watzak: For five years

Nancy Dickey: For five years. So it’s a $4 million grant, assuming you deliver. And it’s called a technical advisory center, so this is not a grant that says to us, go out into a hospital and actually do work or give money. It’s, can you create tools to either help a hospital assess its health or, as we help that hospital assess where its problems are, tools to help them address specific issues and concerns. And, while you’re at it, if I create a tool for Dr. Watzak’s hospital then I can put that tool on the website and other hospitals who say, “Oh I have that issue, I think I can do that,” rather than us having to knock on the door of every rural hospital—there are some 1,800 of them in the country. Every hospital we go to, we will learn from and hopefully they will learn from us and together we’ll try to create tools. So, we talked about telemedicine, and I don’t think we’ve ever been in a small town that a rural health care facility or provider didn’t see telemedicine as a potential part of the solution.

Bree Watzak: Right.

Nancy Dickey: But then we all kind of scratch our head and go, so how do you do that? There’s nothing in the yellow pages that you dial up and say I have no money but I have a lot of need and could you come and set this up for me?

Lindsey Hendrix: Right.

Nancy Dickey: So, we’re working on kind of a primer, if you will. A) Is this part of your solution? B) If it is, where do you start, because you can do telemedicine for R2D2 to make hospital rounds, or you can do telemedicine for just connecting your consultants, doctors that your patients frequently go see and trying to prevent them having to drive back and forth. Or you could say, gee, I’ve got good access to these four specialties but not this one so I’m going to go find a way to do this specialty by telemedicine. So, you have to answer a bunch of questions before you ever start. And then, what kind of questions do you ask when you go find the two or six or 26 companies who, once they hear you’re interested will be knocking at your door? How do you pick a reliable company and what’s a reasonable cost for it and who pays for it? So, that primer is going to be almost a textbook. But to my knowledge, right now you don’t have any place to go that says step one, step two, step three.

Lindsey Hendrix: Mm hmm

Nancy Dickey: So we will be, hopefully, creating tools. We’ll be doing, each year, we’ll do a cycle, an application process for hospitals that qualify, which is, like I said in of about 1,800. We’ll do what we call tier one interface with five hospitals a year. That means we’re going to take a team and actually go to your hospital, sit down face-to-face not only with hospital leadership but with the community because it’s a piece of what we do. And by the time we leave hopefully two days later, we’ll be able to begin to outline with a community the issues they most want to address and the ones that we think will help them either right-size the health care or maintain the hospital, whichever it happens to be. And then we’ll stay in touch with them through ECHO, through email, telephone calls, over the course of 12 months, and we’ll make a second site visit towards the end of each cycle to those five facilities to kind of plan out where they are going to go, when the hand holding becomes a little more far and in between. Then there will be 25 hospitals, so we’ll touch 30 hospitals per cycle, that will get tier two. That means they’ll get fairly intensive, but virtual, assistance. They get webinars, emails, they too will have an ECHO program and the capacity to call and talk to us on the phone, but we won’t actually be going to their site. We’ll collect their information, we’ll process it here and then hopefully, we’ll be able to continue to do some assistance at a much lower intensity for those 30 as we start the process to roll another 30 in a year from now. And, again, because we hope that each one of these interfaces will create a knowledge base about, gee this worked here or you may already have problems but wow, you’re doing this particular thing really well, we’re going to steal that idea and write it up for other people. So, over the course of five years, hopefully, there will be a very robust toolkit that helps you make decisions, helps your community understand the kinds of decisions they’re facing, and then what steps you might take to transition from wherever you are to either a healthier hospital or maybe a different level of care for your community.

Lindsey Hendrix: So we talked about right-sized care when we were looking at posing solutions for rural communities. What is right-sized care?

Nancy Dickey: I think it probably comes from, historically, in the late 1940’s, early 1950’s, President Truman and congress basically promised America that every small town should have a hospital, and they made substantial funds available to help build those hospitals. With different programs over the decades that philosophy has kind of been continued. So, many small towns that have a small hospital are very concerned when conversation occurs that we’re financially in trouble and we may not be able to keep the doors open. Because, somehow, that is an indication that their community is perhaps not healthy when it’s really more of an indication that health care has changed and that Truman generation philosophy doesn’t make a lot of sense any more. So, right sizing care is the process of both knowing what your community—what we call a catchment area, how big a population not necessarily within your town limits but within in your county or multiple counties—how many people look to your community for their health care. That will help define whether you have a couple of physicians or maybe most of the basic specialties family medicine, OBGYN, internal medicine, or maybe no physicians because you’re a very small town and the reality is you hope that you can begin to build a primary health care infrastructure that starts below the level of physician providers. So, right sizing care I think is beginning to understand what size population a community is trying to guarantee access for and how to do that in a fashion that is financially responsible, can promise high-quality care, and part of that promise has to be, and how will we help you connect with the next higher level of care for those things that require a more dense population, whether that’s a secondary level hospital or a tertiary or quaternary hospital. You want those available when you need them but you also want to be sure you have a way come back home as soon as it’s reasonably safe and effective for you to do that.

Bree Watzak: And I think at the center we have the beauty of being a third party and we are not a membership organization. So there are some membership organizations for rural hospitals that do amazing work and help those hospitals, but their mission for their members is to keep that hospital open as it is. We don’t have that constraint, so we can come in and say, yes you’re hospital is absolutely necessary. There’s nothing around for 200 miles, let’s look at how you can stay financially sustainable over the next however long we can help you with that. Or, okay there are three hospitals within 15 miles of you. Let’s look at how we can right-size care so that you don’t shut down and have all your doctors leave town. Let’s look at what you need to keep here so we can help you keep those doctors and those services, and it may not be the hospital that you currently have. So, we have the freedom to do that at the center.

Lindsey Hendrix: I know where I’m from in Corpus Christi, we have some hospitals but there’s lots of urgent care clinics that are popping up everywhere. Is this part of the solution that y’all propose to these communities? Is it sustainable in some of the small towns?

Nancy Dickey: We think there will be towns that are large enough that they really need some place that offers what most of us would consider emergency room care. So, for a number of things, there is something we call the “golden hour.” It’s really important what care gets rendered within the first 60 to 120 minutes after the accident or the symptoms. So for heart attacks, for strokes, for trauma, what happens in that first hour is very important. For a community that doesn’t statistically make sense to keep a hospital, there may still be a need for some kind of trauma stabilization or quick diagnosis and initiation of treatment plans even while transport to the next level of care is occurring. In larger communities, like Corpus, where you have lots of urgent care centers, they provide a very different function than what I’ve just described. They actually cater to our concept that, you know, I’ve had symptoms for 30 minutes and I better go see a doctor. And so, they are far less trauma, big emergency oriented. They are much more, how do you get access to care in a short time without waiting for an appointment. But those kinds of centers in a rural area may, in fact, provide the largest piece of what that community needs without necessarily being tied to inpatient care.

Lindsey Hendrix: Right

Bree Watzak: We looked at a community that had done an assessment of everything that had gone into their hospital, and they figured out that an urgent care center with a specific skill set, I think they had a radiologist, was their one clinician they said we need in addition to, and they said it covered 70 percent of the visits that people were using the hospital for. So they felt that was a better investment with their funds and it worked for their community.

Lindsey Hendrix: So, many of these small towns are losing OBGYNs, but women in outlying areas still need prenatal care and then care during labor and delivery. So, what are some solutions for women in rural areas?

Nancy Dickey: We’re actually working, not through this grant, but through some other resources, to try to address what’s being called OB deserts. When a hospital closes, almost always whatever providers were doing obstetrical care leave because it’s very hard to do OB care without a hospital. In fact, in Texas, there are currently some regulations that say you’ve got to be able to do a C-section within 30 minutes of knowing a C-section is needed. Well, if you’re anywhere except in a hospital that does C-sections, then you’re probably not going to meet that criteria. So, the distances between obstetrical care get longer and longer. Using something like telemedicine may, in fact, help address part of the problem. It’s not a terribly elegant solution, but if obstetrical care family physicians who do OB or OBGYNs were to make itinerant visits—so, identify a geography and go to small town A on two Mondays a month and small town B on two Wednesdays a month and so forth—so that everybody in their first month of getting OB care would get hands-on assessment, real face-to-face assessment, of whether they were low risk. If you’re high risk, you’re going to spend a lot of time in the car, or you better hope you have a relative you can move in with for a while. But if you’re low risk, then there is actually a program in Utah that does some tele-prenatal care. And so, could we shift a lot of the prenatal care to telemedicine with probably one hands-on, face-to-face visit per trimester? And then as you get late in the pregnancy—and again, you’ve got to stay low risk, so don’t push any of those buttons that make you diabetic, hypertensive, preterm labor kind of people—then as you get towards the end of the pregnancy, the frequency of the visits becomes much more. It’s about every week, as a matter of fact. But increasingly, obstetrical care is not at Mother Nature’s beck and call. We schedule it. And so, if you’ve got good timing, if we know when that baby is due based on an early ultrasound, then instead of having to drive frantically through the night when you start having contractions, you can schedule that delivery just so long as you wait until after 39 weeks, and the literature says your outcomes are equally as good. So, this is but one example of things that we’re used to doing close to home that patients will have to identify other solutions now. In Texas, this will probably work reasonably well 12 months out of the year. If you live in Alaska or Wyoming, frankly, they do similar sorts of prenatal care, but when you get into your last four weeks or so before delivery, they tell you move to town.

Lindsey Hendrix: Oh wow.

Nancy Dickey: Some of them actually have…

Bree Watzak: Stork centers!

Lindsey Hendrix: Stork centers?

Bree Watzak: Stork centers. So it is a living arrangement in town close to the hospital knowing that you have to live there for several weeks and you won’t be in your home, and it’s more affordable and more comfortable than getting a hotel room.

Lindsey Hendrix: Wow

Nancy Dickey: Which addresses the pregnant woman and even maybe the high risk woman who can’t do tele-prenatal care because she’s high risk. So, she’s got to be closer to care. But then again, most of us can’t afford to live in a hotel for three months. But what do you do for the woman who has four children at home? So that gets you prenatal care but there’s still some very serious social issues that have to be addressed for this to work. Nonetheless, it is another example of how we try to take the expertise to the patient at least as much, as long, as safely as you can and prevent as much time on the highway as possible. So, OB care is an example. I think we’ll find other ones.

Lindsey Hendrix: So is the hope that these tools, resources, library that you’ll be building, will it be accessible to anybody who runs a rural hospital or doesn’t have a hospital in their community? Is there a fee associated with it? How does that look?

Bree Watzak: It is currently accessible to everybody. We have, in addition to the tier one and tier two, those hospitals that applied and didn’t make the selection this year as well as anybody else who comes to our website, they are welcome to attend our webinars. We have subject matter experts once a month that will talk about issues that are very relevant to our rural communities, so those are open to everybody and as we collect the tools. And we’re going to have a learning management system, so hopefully there will be classes and other things. Those are currently open to everybody.

Nancy Dickey: And that should continue, at least for the first five years while HRSA is funding this because this is a federal program. I’m sure if there was a way for them to say we’ll come visit every rural hospital that they would do that. The expectation, I think, is that in fact as a technical advisory center those tools should be available to any rural hospital. Now, if the funding continues to roll forward after the fifth year, then there’s no reason that it shouldn’t remain free to that entire population. But, if at some point the federal funding stops, it may be necessary to begin to look at subscriptions or consultative fees or something in order to maintain websites and ongoing webinars. One of the things we can tell you, we can promise you, that health care 10 years from now is not going to look like health care does today.

Lindsey Hendrix: Right

Nancy Dickey: So we may come into your hospital, your community and craft a solution that financially looks like it’s going to be the best thing since you opened the hospital and everybody’s satisfied, and then we discover 12 new things over the next decade and all those solutions no longer make sense. I really think it’s important for people across the entire country, but particularly in more isolated areas, in rural areas, to picture in their mind what makes American medicine so spectacular, and that is the tremendous speed of progress. I still see patients a couple half days a week and I’ve got to tell you, the vast majority of medications I write prescriptions for didn’t exist when I went to medical school. I’m not sure they existed 20 years ago. So, many of the tests we do didn’t exist, many of the technologies that we implement to try to keep people healthy or help them live longer even though they have a disease we can’t cure. And so, as those changes occur, we will have to continue to say, what should be available in a small town? What should be available in suburbia? The reality is that this isn’t an issue just for rural America. If you live on the edge of a mid-sized town, you may have access to 50 percent of the technology that we discovered but there will always be things that require a more intensive infrastructure than even a mid-size hospital can afford to do. We have wonderful health care here in Bryan-College Station in a very rapidly growing small city, but there are some things that we don’t have enough call for to be sure that that technology and infrastructure is here 24/7. So there are some things you’ll get care for here and still require a transfer to, we use to call them tertiary now I think they may be quaternary hospitals. But the good news is that we live longer, we live better, and that should be the goal for us for everyone and that means we have to continually look at what we do, how we do it and where we can do it best.

Lindsey Hendrix: That’s awesome. For people who are interested in learning more about the Center for Optimizing Rural Health, where do they go?

Nancy Dickey: The easiest place would probably be to go to the website, optimizingruralhealth.org, and you can explore the webinars, the calendars, the plans. There is additional information about rural healthcare in general at the A&M Rural and Community Health Institute, which is architexas.tamhsc.edu. This is the institute where the center resides and there’s more like 15 years’ worth of information collected there. It talks about a variety of programs and services that the institute offers. It has some of the early reports about rural health and hospital closures that led to the grant for the Center for Optimizing Rural Health. And between the two I think you’ll get a fairly good flavor for what Texas A&M does in terms of rural health care. I hope that students who are going out to spend time in rural sites might want to go and look at it. When we send students to an international site, we ask them to get acculturated to learn a little about it. It might be a good idea to learn a little bit about the different culture when you’re going into a rural area as well.

Lindsey Hendrix: Right

Nancy Dickey: But as the general public increasingly knows that A&M is a source for rural health information, they too might come across either the center’s site or ARCHI’s site and have an opportunity to learn about some of the activities that are occurring.

Lindsey Hendrix: That’s amazing, very interesting. Well thank y’all both so much for coming on the show. It’s great to hear about some of the solutions that Texas A&M is putting out there, I think we’ll have a great impact on rural communities. Not only here in Texas, but across the nation, maybe even the world.

Nancy Dickey: Well, I think the world is a little bigger than we are. But we’ll see. Thank you for having us. We appreciate the opportunity to share and hope that some of your listeners will take the time to check out the websites.

Lindsey Hendrix: Sounds good. Thank y’all so much.

Bree Watzak: Thank you.