In this episode we learn about what it is like driving value in rural communities with CHESS Health Solutions senior director of clinical operations and practicing physician Dr. Kimberly Vass-Eudy
Dr Vass-Eudy, as a provider with a rural patient population what are some of the unique challenges about practicing medicine in a rural community?
I think the first thing is that the space there's a lot of space in a rural health community. Patients are driving many miles to get to restaurants or grocery stores or to their doctor, so it really does create an issue for some patients especially in a in an economy where there's issues with paying for gas or food. So for a provider in a community like that, they have to be really aware of that distance. It creates community though because a lot of people families will stay in the same area together.
So when I was working in a rural health community facility, I would take care of everybody from great grandma all the way down to you know the tiniest infant because they all live nearby they all kind of stayed together and created a community. There's a lot of people in my practice that knew each other which was nice because they would take care of each other and look out for each other and so it was a different concept to me than maybe working in a bigger city where people don't always know each other
And what factors are driving poor health in rural communities?
So one of the biggest issues with the rural health community is just learned behaviors. Maybe this is a rural area where there was farming in earlier generations and so eating biscuits and gravy and putting lard in everything is acceptable because you're going to burn off those calories working in the farm from sunup to sundown. But in a more in a in a time when that is not the issue, when they're not working in the in the fields they're working in a factory job and they're coming home and sitting on the couch, those same patterns of eating behaviors not exercising you know veging out on the couch is something that kind of perpetuates bad outcomes or bad health.
So I've seen that a lot just - well that's how grandma cooks so that's how I cook and really having a hard time not putting a meat with every meal or you know meat and potatoes with every meal putting gravy on everything. That's something I've had to really try to work with patients on. I think diet and having that education for patients in a rural health community is something that's really lacking and just that learned behavior trying to unlearn it for healthier at lifestyle
And how are these challenges uniquely suited for practicing value-based care?
I think what I've learned especially now that I'm part of CHESS is that we really look at the data. We're not making a blanket statement about a group of patients. We're really looking at what those needs of those patients are in their setting. So, what is necessary for rural health practice may not be the same as for an urban practice. I like the idea that we really look at what the needs are and then try to come up with solutions to solve those problems. So, for instance in a rural health community, there's an increased risk of hypertension, diabetes, tobacco use, so we would tailor projects and pilots and processes that would help patients in those settings and for those diseases that may not be the same as in an urban area.
And you really can't bludgeon them you know you can't beat them over the head about it it's a process they have to come to the realization that this is something that they want to do for themselves. I just recall a patient of mine. She always this always makes me laugh because she was a diehard smoker, she said you know Dr. Vass-Eudy, when I die my hand is going to be sticking up out of the grave with a cigarette in it. I'm never quitting. And I said OK well lets you know we just talk about it every time - hey are you ready are you thinking about it and finally she quit. It was her decision though and it was just being supportive of her in that process. But she did quit and she's not you know with her hands sticking up out of the grave with this cigarette in it.
Well thank goodness! Dr. Vass-Eudy, how do rural providers increase patient engagement to be more invested in their own health?
Honestly you just have to meet the patient where they are. You have to care have to care about where the patient is coming from what their specific needs are. I think if you are in a real health community have to be part of it in a lot of ways even if maybe you don't necessarily live there. But you have to take part in the community like community outreach. I remember going to senior centers and having lectures to the seniors in the rural health area. I remember churches and bazaars and just doing different things to educate patients, bringing medicine to them, bringing the blood pressure cuff to them, talking about diabetes screening at these different functions to try to get them to understand that I care about their health.
I think if a provider in a community shows that they're going to get engagement from their patients, their patients are going to know that they care about them. It's a little bit easier to do this sort of outreach when you have a smaller not busy practice and kind of a newer provider in a community, but I really hope that any provider in any community will take part in the area and what's going on with their patients.
What are the advantages for the patient, care team, and clinicians for providing value-based care?
It gives a road map to success for the patients’ health outcomes. If you are practicing value-based care, you're looking at what is most affecting your patients and you're coming up with solutions to benefit them, and if I'm benefiting my patients, that's my whole the goal of my job. That's what I'm trying to do. It's all about them. So, with value-based care, because we're always looking at the numbers and watching and seeing and what's happening to the patient, how well are we caring about them, we can find where there's holes where there's places that we can plug in care team members nursing staff, home health education, diabetes education, dietitians. Like we can see where those places are and really meet the patient where they are.
We spend too much money in healthcare for really bad outcomes, so the goal is to flip it pay less and get better outcomes. That's the whole point of this. I don't like to think about the payment part of it because I've never liked that even as a healthcare provider. I'm the worst at this. I never know what my paycheck is. It just goes in the bank like I don't pay attention to that. But I know that we're spending too much money. I know that we have the greatest country in the world with the greatest health care in the world, but we're spending so much money and we're getting very little for it. Patients are no better off. So we have to do something and if it means we look at the bottom line at the same time as looking at quality as well. If I'm spending all this money, why am I not getting anywhere with patients? I need to figure out how to take better care of them and not spend as much money.
In our country there's been an ongoing debate about rural telecommunications, and when COVID hit it became more imperative that we become more interconnected through the web. How have you seen technology be a barrier in these communities within the healthcare space?
Oh yeah. I mean you hit the nail on the head. They just don't have access. They don't have the I guess the high speed Internet that maybe I can get in a bigger city. And I've had patients who live off, you know, a dirt road and to have that kind of access is going to cost them tens of thousands of dollars that they don’t have, because no one's paying for it. They want better access; they're going to have to pay for it. So I think that is truly an issue.
There is definitely and there's definitely a difference between a wealthier community and a poorer community and what kind of access they have. I would hope that we could find other ways around that because it doesn't mean that they don't need or deserve the kind of care that other people are getting. Virtually, I do a lot of phone visits. I mean, I may not see the patient. I've even done some face times on my cellphone, whether or not that's approved by you know corporate or not. I'm like, that's one way I can see but let me see your wound we're on FaceTime with my phone because they cannot access the computer Internet. So I think that we can work around it. It's got to happen. I think people need to put pressure on their leadership, the government leadership in their rural communities, to get that sort of access that we all deserve because that's where we're heading. You know I would love to see more medicine done at home. Why do you need to drive 45 minutes to my office when I could have done this over the telephone? So I'd like to see more of that and I think we can do that.
Have you also seen a technology barrier within the practices itself that have caused it to struggle with patient care?
I think so I mean I think a lot of people - everyone's a little resistant to change and we had to change really fast during COVID. I've never had to do a pivot in my life like that. As far as my practice, it definitely changed how I perceive things and how I do things. I was dead set against doing anything on the telephone because in my mind I thought I have to listen to the heart and I have to listen to the lungs and I need to put my hands on the patient and I learned really quick that I can do a lot without having my hands on the patient. I had an attending once who told me think about it as if you're - this was many many years ago getting older - think about it as if you're if you're practicing in the jungle. Like what are the basics that you need to take care of a patient and I've always kept that in my mind because we do get really reliant on technology, X-rays and images, and things like that. And I remember him saying that and I would think about it a lot during COVID. Like what if I'm in the jungle? What do I need and so I could do a lot without a lot you know taking care of patients? So I think people are resistant to change. So maybe some people are not willing to do things differently than they've always done them.
We're always researching and trying to figure out do I we need to do pap smears every year? No we don't do I need to do certain tests every single year. No I don't because we've studied that and it's just historical and we've always done it that way so we always will. So I think it's nice to think outside the box a little bit and see if we can do something different.
So tell me Dr. Vass-Eudy, how can clinicians leverage partnerships with community based organizations to improve patient care?
Great question. I've definitely have learned a lot just working with CHESS on how I can partner collaborate work with others. When you're a doctor, especially a rural health doctor, you really learn how to do everything yourself because I have no one else to rely on. The patient walks in with a wound you know fingers hanging off or some kind of wound from a farm equipment. I'm the one who's going to handle it because there's nowhere else for them to go. So I've had to unlearn that I have to understand that I'm not the only one and then I can leverage other people's knowledge and experience and expertise and gifts that I can bring all of that to the patient not just me. There's so much more that can be brought so I had to unlearn that myself and I find that utilizing dieticians, diabetes educators, nurses that will call the patient and talk to them on the phone, um pharmacist my gosh they're so underutilized on what they can offer patients, their doctors as well. So getting a team together relying on your team not thinking you're the only one who can take care of the patient but there's so many people that can help and the patients appreciate that. They love it they want that team approach. They've often, you know, over the years people would say well you know they were disappointed in something their doctor did, but when you have a team, it's a whole group of people deciding and helping and throwing, in you know, their two cents. So it's not just relying on one person to do it. There's an effort from everyone.
So now with a greater awareness of social determinants and the big push to alleviate those barriers, do you see opportunities outside of the clinical space for partnerships that can support hunger, job training, or Family Services all to create a better collaborative effort for patient health and wellness?
Absolutely. There is such a lack of connection with resources in the community. I have often, especially in a rural health area, have been disappointed or frustrated with trying to get help for people. I've had patients who didn't have electricity because some wiring on the outside the house. Something was wrong. So then we're trying to leverage all these different people in the community to help. Churches, organizations, but I don't know who they are. I had to start from zero. I don't know who to ask. So my staff and I and just getting on the phone and calling people to try to get help. So I definitely wish there was more of a concerted effort to partner with groups in the community that can help patients with things like, you know, electricity issue or a, you know, broken window or something that that is kind of not exactly healthcare but it does impact a patient health.
What opportunities do you see on the horizon for improving pop health in these rural communities?
Partnerships definitely. Outreach is another one. Getting patients comfortable with having other people than their doctor calling them on the telephone. So, but coming at it as a group my nurse my pharmacist this is I'm representing Dr Vass-Eudy because patients are going to be reluctant, especially our older community. They're always thinking somebody is trying to scam them. So I really would love to see that grow where the patients understand that it's not just me, it's an outreach from my office and it's there for them.
I'd like to see more monitoring devices at patients home so blood pressure cuffs, glucometers um, you know, congestive heart failure devices where we're measuring fluid overload, so things like that to help the patient at home. I want to see more things done at home for the patient. I'd like to see, you know, more education. Whether it's groups at a Senior Center. I brought a dietitian to the Senior Center and had everybody come over there, the community as well as my patients, so that the dietitian can give them some education about what to eat what not to eat as a diabetic. So I'd like to see more of that. Definitely groups collaboration and outreach and coming at it from the perspective of helping your doctor help you.
Well Dr Vass-Eudy, what can a provider do right now to start seeing better outcomes for their rural patient population?
A provider needs to care about the patient, especially in a rural health community. They're a special group that requires a doctor or provider that really understands that group. They're loving and wonderful and sometimes they're sassy and sometimes they don't want to follow your advice and sometimes they're going to come with their own things that they've done because mom told them back in the day this is what you do. So there's so many interesting parts to that patient-provider relationship that I really could. If someone would just care about that and really meet the patient where they are, I think that that would make all the difference in the world.
Over the years I have had patients that if I could if I just show them I cared, they were dug in their heels were dug in they or going to do something that I asked them to do that was in their best interest, but I just kept staying with them and just kept hearing them out and over time they came around. You know, they really said I appreciate what you've done. I appreciate that you cared, appreciate that you showed up and that you're here for me. And I think that's what's important. Baseline basics for any provider. Just be there for your patient. Care about them.