Dartmouth Health is the most rural academic medical center in the country, and like other rural hospitals and health systems, it faces challenges that affect its ability to attract and recruit top talent.  In this conversation, Joanne M. Conroy, M.D., CEO and president of Dartmouth Health, and 2024 chair of the AHA Board of Trustees, shares how Dartmouth Health has implemented workforce solutions that can be successful anywhere.  

Tom Haederle

Clean air, peace and quiet, and quick access to outdoor activities are among the draws of practicing health care in a rural setting. On the flip side, issues such as housing, transportation and affordable childcare remain challenges for all rural hospitals and health systems, and affect their ability to attract and retain top talent. Stay with us to hear how the leader of the most rural academic medical center in the country has faced those issues and produced solutions that work.

Tom Haederle

Tom Haederle

Ideas that could work just about anywhere. Now to Shannon.

Shannon Wu

Joanne Conroy, M.D.

Joanne Conroy, M.D.

And that was actually a great experience, kind of contrasting academic medicine in a kind of a regional institution, to going to northern New Jersey, where you had all the influences of metro New York. After eight years at Atlantic, I went to the AAMC, the Association of American Medical Colleges, where I was their chief health care officer. And that was really great because I really got to see policy and the impact of policy on practice, and I was actually there,

Joanne Conroy, M.D.

Joanne Conroy, M.D.

Joanne Conroy, M.D.

I've had the opportunity to have really a great kind of experience in almost every different type of health care system. And then when I was at the AAMC, I got to look under the hood of 185 teaching hospitals, which really gives you a perspective about the differences across the country.

Shannon Wu

Yeah, you're right. That is such a varied set of experiences you've had. I understand that you are one of the most rural academic health systems in the country. Please tell us a little bit more about Dartmouth Health and the rural population specifically that you serve.

Joanne Conroy, M.D.

You're right. We are the most rural academic medical center in the country. And people say, well, how do you know that? They actually see how many people live within 30 miles of the academic medical center. And we have only 170,000 people within 30 miles of Dartmouth Hitchcock Medical Center, which is our academic site. And the next most rural is Mayo, which has about 230,000 people.

Joanne Conroy, M.D.

And then you have a number of organizations like University of Virginia, Carilion Clinic, that actually have small city populations. I would say, Dartmouth Hitchcock, when you kind of think about how did we get here? And really we sit on 200 acres, and you wouldn't even be able to see us from the highway. And yet, when you turn down the roads that bring you to the institution, all of a sudden you have over two million square feet of research infrastructure, clinical services, outpatient services, as well as the Hitchcock Clinic offices.

Joanne Conroy, M.D.

And, you know, people drive two, three hours here to get their care. Rural health care in New England is probably different than rural health care in the Midwest, which is different from rural health care in the Southwest. They all have a little different flavor, but they all share many of the same challenges. When you think about the importance, however, 20% of people in the U.S. get their care from rural hospitals, and we have made a commitment to actually supporting what we call the rural safety net, which bridges New Hampshire and Vermont.

Joanne Conroy, M.D.

That's been the focus of not only the hospitals that we bring into our network, but also the services we invest in to allow care to be delivered locally and for people to stay in their communities.

Shannon Wu

Yeah, that's great. And let's dig into some of the challenges, that comes with serving patients in rural communities. We know that health care workforce has experienced many challenges, especially during this past few years. There's both a nursing and physician shortage, and it must be very tough to recruit and retain the clinical workforce that you need, in such a rural footprint.

Shannon Wu

What have you done at Dartmouth Health to address some of these staffing challenges?

Joanne Conroy, M.D.

So, yes, and no. So yes, it's a challenge, but there is a certain type of person that actually wants to live and work in a place like Dartmouth Hitchcock. So let me first talk about our attitude towards remote work. We took all of our jobs at the academic medical center and decided which ones were going to be permanently remote.

Joanne Conroy, M.D.

This was probably a year, a year and a half into the pandemic, and we have close to 2,500 people that are permanently remote. We employ people in 35 states, which makes some of our tax people a little bit crazy because we have to, you know, make sure that we adhere to the employment law in every single state and file all the forms.

Joanne Conroy, M.D.

But what it does allow us to do is actually find talent all across the country and actually leverage that talent. So our performance network is scattered across the country, but we have incredibly talented people that we could not recruit if they actually had to be within, you know, 45 minutes of Dartmouth Hitchcock in order to be on site.

Joanne Conroy, M.D.

And another thing we found out is that often we have professional marriages, and in rural America, it's not just the person you're recruiting, it's their partner as well. And they have to find gainful employment. So a lot of this is solved by really remote work and really getting good at remote work. The second thing are nurses and physicians.

Joanne Conroy, M.D.

And, you know, people love working up here. I mean, if you love really being in the outdoors, we are literally 15 minutes away from a ski slope, and in five minutes you could be on your bike mountain biking, and a lot of people do ride to work, and a lot of people have kayaks on the top of their car.

Joanne Conroy, M.D.

And, you know, it's less than 10 minutes and you're flipping that into the water, so you can actually really enjoy the outdoors here and don't have to travel two or three hours to do that. You're actually living in this wonderful place. Unfortunately, our issues are the same across the country. Housing, transportation, childcare services, all the things that are less of a challenge in the city.

Joanne Conroy, M.D.

We actually are subsidizing housing for our clinical frontline providers. And we've been talking about building housing. It's just it's that bad. Now, we know that once we start doing it, everybody else in the community is going to say, that's not a bad idea. How can we actually use the same approach to actually developing workforce housing? I would say that we invest in transportation.

Joanne Conroy, M.D.

We know that not everybody wants to drive to work, so we actually support a lot of our local transportation systems from our small city hubs where most of our employees come from. And finally, childcare. You know what distresses me the most is 10% of all the women that left the workforce during the pandemic have not come back. For many of them, it's a lack of affordable and accessible childcare.

Joanne Conroy, M.D.

So we've invested a tremendous amount of time and effort to actually educating more early childhood educators so they can either participate in the large centers we have, and we have a number of them, and or start small businesses in their home where they can take care of kids in their home. And, you know, my hope is this way we make it easier for women to come back into the workforce because we're 85% female, and we know that having 10% of that workforce not be available is a huge issue for us.

Joanne Conroy, M.D.

But, you know, those are the challenges that they face in many other rural areas of the country.

Shannon Wu

As you alluded to, social drivers of health have also become more recognized as a major contributing factor to overall health. And as you've just mentioned, as really Dartmouth Health as the anchor institution for your community. Like many other hospitals and health systems, it is committed to promoting well-being and addressing societal factors that influence health. You had mentioned, you know, your investments in transportation and childcare services and housing.

Shannon Wu

How are hospitals and health systems working with community partners to address these social drivers of health in Dartmouth in particular, and other conversations you've had with other rural health leaders?

Joanne Conroy, M.D.

Well, we have a Center for Advancing Rural Health Equity, which is really focused on operationalizing how do you improve health? Over half the people on the board are actually community health organizations, housing authority, food banks, you know, people that are living every day trying to actually improve the conditions in which people live that are critical to maintaining their health.

Joanne Conroy, M.D.

They actually did a really interesting study about three or four years ago, where they identified the decrease in average lifespan from Hanover to Lebanon to Grantham to Newport to Claremont, and the difference between Hanover and Claremont, which are probably only separated by 20 miles, is about 15 years. When you look at the, you know, the drivers of health, they're actually very different in those communities.

Joanne Conroy, M.D.

The Hanover community is populated with a lot of professionals from Dartmouth Hitchcock, and also professionals from the college. And Claremont, it's an old mill town, and a lot of people that get the work done every day, but often in blue collar jobs or jobs that don't pay as much. And we look at the correlates between income, education, access to care.

Joanne Conroy, M.D.

There's a huge difference. What's great is today we actually celebrated the fact that that hospital in that community is actually joining us. And our hope is that that hospital that's anchored in the community and using all of our resources in terms of expertise, our telehealth, our back office resources, so that organization can actually have a greater return on the community investment and then reinvest it in their facilities and programs, will ultimately improve the health of the community at large.

Shannon Wu

That's great to hear. The next question is going to be a two-part question and how we talked about some of this, but what are some of the other challenges you see that face rural hospitals and providers, in delivering care to their patients? But then, hopefully to end on a positive note, what innovations and opportunities are you seeing in this space as well?

Joanne Conroy, M.D.

We have actually looked at hospital at home frequently. It is hard to do it in a rural community when internet is spotty, questionable, consistent electrical and water sources. We talk about how do we deliver care in the homes differently. We do have a visiting nurse and hospice association, and I've actually gone on a lot of their intakes.

Joanne Conroy, M.D.

And I'm so impressed how they just kind of take the patients where they are and say, how can we actually appreciate this environment so this patient can get better and will no longer need our services. So those are some of the really unusual challenges. On the flip side, we have some remarkable innovations. We have a super strong, telehealth program.

Joanne Conroy, M.D.

It's interesting, it’s provider to provider. So we actually provide the care to outpatient clinics, to hospitals, to physicians’ offices. And a lot of that is so people don't feel like they have to refer everybody to the academic medical center. But if they have a simple question or want some guidance in terms of how to deliver care to that patient in their rural office or in their rural hospital, that we can actually give them the answer right away, and that patient can have some resolution of what their care plan is going to be.

Joanne Conroy, M.D.

We also have a lot of physicians that do a lot of traveling. They get in their cars and they work in clinics. Often our emergency room physicians travel all over our rural network, and that actually allows for a great exchange of ideas between the physicians that are at those facility, interacting with physicians from the academic medical center. And, you know, it's an incredibly positive relationship that actually enhances the systemness that we have, and actually improves the ability of people to actually keep people in their community.

Joanne Conroy, M.D.

And finally, we used ECHO, the ECHO program a lot during the pandemic, not only to educate people about COVID, but we actually have used it on all the specific disease challenges we face in the communities: substance use disorder, stroke, cardiovascular disease, liver disease. So people in the community feel like they get the resources they need to care for patients.

Joanne Conroy, M.D.

And, you know, after the Dobbs decision, we're offering ECHO programs through emergency rooms across the country because with the diminution of women's reproductive health services and maternity services across the state, we know that many of these patients are going to be going to emergency rooms. And those emergency room providers are ill equipped necessarily to take care of women in active labor, or a woman whose pregnancy is at risk.

Joanne Conroy, M.D.

So we have an OB kind of Maternity 101 for our emergency rooms. And our hope is this will help people stabilize those mothers before they needed to be transported to the academic medical center.

Shannon Wu

Shannon Wu

We're very thrilled that you'll all be there to discuss the topic of rural health delivery. So thank you for your time, Joanne, in joining us in San Antonio. And we hope everyone who is listening will also consider heading to Texas for that event. So once again, thank you very much, Joanne, for being there. And thank you to our listeners.

Joanne Conroy, M.D.

Thank you, Shannon. It's great to be here.

Tom Haederle

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