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Community Health on the River of No Return

Tuesday, June 20, 2017   (0 Comments)
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Lynn Gerlach, Tamarack Communication


The four-seater Cessna 206 putters along above the treetops, a backcountry pilot at the controls. He has two passengers: a search and rescue volunteer and Danny Fife, PA-C, on call at the local Federally Qualified Health Center. They have several hours of daylight left, which is good, because somewhere in the forbidding terrain below lies a woman with a broken ankle, and she needs to get to a hospital. 


Communication has been spotty. Signals have been bounced to Canada and from there to the sheriff’s office in Challis, Idaho. In the meantime, the woman, who fell and broke her ankle 24 hours ago, has been floating downstream to a place where she can rendezvous with her rescuers. With the little information he has gleaned, the pilot sets the craft down on a dirt airstrip on the side of a mountain. Danny finds his patient and stabilizes her and, with the help of the search and rescue volunteer, loads her onto the small aircraft on a makeshift backboard.


They fly the patient to the nearest Critical Access Hospital, and then Danny is taken back to Challis, where he’s still on duty. He came to Challis from Virginia right out of PA school, looking for adventure. He’s found it.


Photo Credit: Christine Ollar, LPN


You see, the area into which this team was flying happens to be the largest contiguous wilderness area in the lower 48 states. No roads, and just a few dirt and gravel airstrips that were grandfathered in when the area received its federal designation: Frank Church River of No Return Wilderness - nearly three million acres of land and water.  


Right on the eastern edge is Challis, population 1081. Danny hit the jackpot! 


Challis Area Health Center has been around since 1975, when, according to local folklore, a well-to-do businessman was bitten by a rattlesnake and was incensed that he had to travel all the way to Salmon to see a doctor. He appealed to the Marmot Foundation, they donated $5000, and the rest is history – as it can be written only in this neck of the woods. 


The health center is “a cross between a frontier clinic and a wilderness clinic,” according to Executive Director Steve Rembelski. For much of the past 20 years Challis Area Health Center (CAHC) was run by Steve’s predecessor, Kate Taylor. Kate had vision, and she was willing to learn what she needed to in order to make the health center succeed. To prevent burnout, she established an unconventional work schedule for her providers, all mid-levels, offering them healthy work-life balance.  


Kate had good back-up too, in the person of one Richard Paris, MD, her Medical Director. Twice a month Dr. Paris would fly his own little Cessna from Sun Valley to Challis, a 30-minute flight that would have been a grueling two-hour drive by car. He’d see patients, including OB patients whose babies he would likely deliver in Sun Valley, and he’d consult with his team of mid-levels. 


Perhaps the crowning glory of Kate’s tenure was application for a Section 330 grant, to make CAHC a Federally Qualified Health Center. She won her grant in August 2015 and then resigned her position to go in a new direction. Her board searched for a new Executive Director. Twenty-two people applied for the job – and they hired the local bank manager. 


Enter Steve Rembelski, a local fellow, born and raised just a few miles from Challis. He and his high school sweetheart-wife had returned to Custer County twenty years prior, educated, successful professionals, hoping to raise their children as they had been raised. Steve worked in banking, and he saw the burnout there and in every other sector of the workplace. He took the job at the health center. 


Steve immediately did two very smart things: He embraced the important changes Kate had made as she transitioned the health center to FQHC, and he asked her to stay on, part time, as his mentor. She agreed, which was a very good thing, because his first HRSA site visit was coming up in five months, and he still hadn’t deciphered half the acronyms in his files. 


The site visit did not go particularly well. The health center passed on 11 of the 19 program requirements. Demoralized, Steve asked his project officer whether they had failed. No, he was told; you got a B. Now you can start working toward an A+. 


And so, with Kate by his side and four dedicated mid-levels and a staff of eight more, they got to work. Within a year, the health center was fully compliant, seeing 18-20 patients a day, with an eye on quality measures and a determination to keep getting better and better. 


A fundamental piece of their current success is a unique provider staffing model, partly Kate’s legacy. The four providers – two PA-Cs and two NPs – work an interesting four-week rotation. It goes like this: 

·         Week One – work Monday, Tuesday, Wednesday 

·         Week Two – work Wednesday, Thursday, Friday 

·         Week Three – on call 24/7 

·         Week Four – off duty


So, while Provider #4 is off, having family- and me-time, Provider #1 is working the first three days of the week, Provider # 2 is working the last three days of the week, and Provider #3 is on call the whole time for emergencies, overflow, patients who need to be seen outside of regular hours, and ambulance runs. All four mid-levels are certified “ambulance based clinicians,” and they get to test their skills most days. It’s not unusual to go out with the ambulance two or three times in a shift. (Danny has had a six-ambulance-run day.) Flights into the wilderness are much less common, however. 


That doesn’t mean things always go by the book. According to Deana Andrews, MSN, ARNP, FNP-BC, it’s not unusual to have one provider caring for the patient while another is on the phone, arranging for transport that might very likely include both an ambulance and a helicopter or small plane. “A few times the approaching plane has had to turn around due to weather conditions,” she explained. “Then we go to Plan B.” 


Deana credits the unconventional work schedule with drawing the team closer together. “We ask for help from our peers. They give us second opinions. They’ve got our backs.” She came from Oklahoma with a lot of family healthcare experience, also hoping for some adventure, but she appreciates the stability too. “We are our own worst critics, but in a positive way,” she said. “We’re always looking for what’s not working as well as it might, and we figure out how to improve it.” 


Christie Ollar, LPN, is tasked with tracking and reporting on quality measures – and she thinks they’re pretty good. “We just got our Athena electronic health record last year,” she reports. “Our patient population is growing, and we’re working with a number of community service agencies. We recently established a patient Care Line so people can call in for medical advice from the on-call provider.”  


Christie got excited when she saw the 2017 PCMH standards, and she said, “Why not? Let’s get started.” Hoping to earn that recognition, Christie holds monthly quality meetings with the staff. Right now they’re focusing on past-due testing and post-hospital discharge care coordination to reduce readmission rates. Their patient portal is up, and they’ll start promoting it seriously next month. “My goal,” Christie says, “depending on staffing, is to earn PCMH recognition next year.”


The man at the helm is just as positive. “We get $650K from HRSA, and we use it to pay salaries,” Steve said, “and I’ve got a great staff.” UDS measures suggest CAHC is similar to the average FQHC, if such exists, with a patient population battling heart disease and diabetes, all below 200% FPL and half below 100% FPL, with 15% uninsured.  


Chances are Danny will one day get to join another flight into the wilderness, and another helicopter will leave them in the lurch, but it’s a pretty good bet this can-do team is going to come out on top. And Dr. Paris? He’s still flying in twice a month to provide leadership and support. 


The author was not compensated by NWRPCA or the health center.



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