Revitalizing Health in Rural Appalachia

Sequatchie County, located in southeastern Tennessee, is part of the south-central Appalachian region.

Sequatchie County, located in southeastern Tennessee, is part of the south-central Appalachian region. Southeast Tennessee Development District

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How a Tennessee county improved community health after the area's lone emergency department closed.

Sequatchie County, located in southeastern Tennessee, is home to an active biking community and boasts greenways and sidewalks that encourage walking. Residents there smoke less, have fewer sexually transmitted infections and have better access to exercise opportunities than other Tennesseeans, according to the most recent county health rankings. They’re also less likely to die from injury, stroke and heart disease—all stark turn-arounds from 2010, when the community’s only emergency department closed and residents struggled to find ways to address their health problems.

The standalone facility in Dunlap had been operated by a variety of providers for more than 20 years before Grandview Medical Center made the decision to shutter it, citing financial losses. It was the only emergency department in the region, and after its closure, residents needing immediate care were forced to drive 40 miles through the mountains to Chattanooga. Many decided it wasn’t worth the bother, then saw their health conditions worsen as a result of lack of care.

At home in Sequatchie County, residents could still see primary-care providers, but often weighed the necessity of addressing acute or urgent needs—a chest pain that came and went, vision that blurred occasionally—against the inconvenience of making the trek to the hospital, said Sequatchie County Executive Keith Cartwright.

“And more often than not, you’d have people saying, ‘I’m not driving all the way to Chattanooga for this little chest pain,’” he said.

Health was already a concern in the area. The county, home to roughly 15,000 people, ranked 74th out of the state’s 95 counties in 2011, with particularly low rankings in quality of life measures, including the number of days residents experience poor physical and mental health. Two years after the emergency department’s closure, that ranking plummeted to 89th.

The county sits in the south-central swath of Appalachia, an area with higher mortality rates in seven of the leading causes of death in the United States, including heart disease, cancer, diabetes and drug overdose.

“The Appalachian Region’s number of physically unhealthy days, mentally unhealthy days, and prevalence of depression are all higher than the national averages for these measures,” as are incidences of obesity, smoking and physical inactivity, according to a recent report from the Appalachian Regional Commission, or ARC, a federal-state partnership based in Washington, D.C.

The closing of rural health-care facilities is rampant throughout the region, the report notes, as Appalachia “has lower supplies of health-care professionals when compared to the United States as a whole.”

Despite the issue’s ubiquity, elected officials in Sequatchie County were not immediately certain how to respond to the closure. They decided to approach the problem holistically, asking what, specifically, the community needed to improve health on a large scale.

“That issue became a top priority for the chief local elected officials, and it all started from the standpoint of, ‘Our people need access to health care,’” said Beth Jones, executive director of the Southeast Tennessee Development District, a nonprofit organization that helps local governments with economic development and planning, including health care. “We began by convening a coalition of all the local elected officials to discuss the state of health care in the region.”

The group discussed the health care assets available in the community. Were there open, accessible clinics? Were they being utilized? What types of services did they provide? How did people see specialists? Most importantly, Cartwright said, officials asked, “Where do we begin?”

Reopening the emergency department was a priority, they decided. The group issued an informal challenge to health care providers in the region.

“We said, ‘Come to us with a regional approach on how we might better enable our citizens to have access to health care, especially in parts of the region that have none,’” Jones said.

Among the recipients of that message was Erlanger Health System, a public, multi-hospital health organization based in Chattanooga. Erlanger had no presence in Sequatchie County but was leasing and operating a rural hospital in a nearby county. Joe Winick, lead executive for the Erlanger Innovation Center, previously had spent time in the county and was intrigued by the idea of restoring care there.

“We started talking about potential solutions,” he said. “I thought the best solution, instead of the people from Sequatchie County coming to Erlanger for health care, was Erlanger coming to them. But, initially, people at Erlanger didn’t think what I was suggesting was even feasible.”

Winick, along with county officials, worked to get federal and state authorization to reopen the emergency department. After years of negotiations, investments of $250,000 from ARC and the county, and a long-term lease agreement for $1 per year, Erlanger reopened the 12,000-square-foot facility in July 2014, featuring 24-hour care for children and adults. Doctors could treat common ailments, from broken bones and sports injuries to bouts of the flu, while patients suffering from more serious issues—stroke, heart attack—could be air-lifted to other facilities.

Within 10 hours on the opening day, 13 patients came for treatment, one of whom was flown by helicopter to Erlanger’s main campus in Chattanooga.

“He came in with chest pains and took a Life Flight to the main campus,” Winick said. “That first day, we saved somebody’s life.”

Erlanger had projected that the emergency department would serve 5,000 patients in its first year. Doctors there saw nearly twice that amount. Currently, the facility sees more than 10,000 people annually, Winick said.

Soon after, health outcomes in the community began to improve. Sequatchie County’s ranking leapt from 80th out of 95 Tennessee counties in 2014 to 74th in 2015, to 63rd in 2016. This year, the county ranks 53rd. Sequatchie also performs better than expected among Appalachian counties in several key metrics, including mortality rates from injury, stroke and heart disease, according to ARC.

Officials said they believe the improvements are at least partially due to the reopened emergency department. The facility expanded after opening to include primary-care physicians, a radiology department and several community initiatives, including an “Erlanger Health Notes” program that sends health-care professionals to county meetings every month to speak about a different care-related topic, Winick said.

By itself, a large-scale health system committing to care in a rural area is rare, according to Hilary Heishman, a senior program officer with the Robert Wood Johnson Foundation, the largest health-care nonprofit organization in the country.

“Lots of small health systems are closing and you see much less opening in rural settings,” she said. “That doesn’t happen every day in this environment in which hospitals are closing all over rural America. That, on its own, is noteworthy and special.”

But the county’s health improvements are likely also due to a network of community programs and initiatives that have been aimed at educating and providing residents with health-care options for years. Those include an active faith community, a 40-member health council that meets monthly to address local issues and a motivated and engaged retiree population.

“When you talk about people’s health in their community, their minds often go to health care, often to the absence of all the other things that we know contribute to our well-being,” Heishman said. “This community has a long history of people coming together and figuring out what they can do to make it a better place to live. The emergency department builds on a lot of other building blocks that they have put in place over the last few decades.”

It’s also due to community-wide health-care initiatives that gained momentum after the department reopened, said Cartwright, the county executive.

“It’s a public commitment to healthier behaviors, educational programs, event participation, regular exercise, health screenings, medical checkups,” he said. “Things like that that really call for us to go far and above just access to health care.”

Erlanger and the county hope to continue to build on that progress. The health system is aiming to open a $32 million, 25-bed critical-care facility in Dunlap where patients can have surgery, stay overnight and eliminate the need to travel for more complicated procedures. It’s the next step in the area’s ongoing health evolution, Cartwright said.

“When we started this we didn’t know where it would go, but we knew there was a problem,” he said. “It seemed incomprehensible that you didn’t have better accessibility to health care.”

Kate Elizabeth Queram is a Staff Correspondent for Government Executive’s Route Fifty and is based in Washington, D.C.

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