For the past five years, travel nurse Karla Theilen has packed up her stethoscope, scrubs, and running shoes and left her home in Missoula for days at a time to fill staffing shortages at small hospitals throughout western and central Montana. Superior, Cutbank, Harlowton, Lewistown, Shelby — she’s worked at medical facilities in all of them, filling in for anywhere from one shift to three weeks, per her arrangement with Monida Healthcare Staffing Solutions.
This spring she was scheduled for a string of shifts at Mountainview Medical Center, a 25-bed facility in central Montana’s Meagher County (pop. 1,862). White Sulphur Springs, its county seat, is located 75 miles from the nearest stoplight. Birthplace of the late writer Ivan Doig and home of the Red Ants Pants Music Festival (whose scheduled July 23-26 event was recently cancelled), White Sulphur Springs hosts hunters and hot spring-soakers, ranchers, and skiers. The hospital is there to provide care for them all.
When Theilen walked in the door for her nighttime ER shift on March 30, a Mountainview Medical Center staff member took her temperature, as recent protocol dictated. It read 101 degrees. The staffer took Theilen’s temperature again, and then once more. It was still high, so she was sent home for fear she might be carrying COVID-19. She returned to Missoula, was tested for the coronavirus the following day, and went home to self-quarantine while she awaited results.
Mountainview Medical Center had a recent brush with COVID-19, so staff had been particularly cautious. Like other rural Montana hospitals, Mountainview can’t afford to risk a community-wide infection. Its staffing model is too lean, its stock of personal protective equipment (PPE) too limited, and its community too tightly knit to risk losing health care providers for an extended period of time.
On Wednesday, March 25, a receptionist had returned to the clinic from an out-of-town trip the prior weekend that resulted in exposure to a COVID-19-positive individual. Immediately after learning of the receptionist’s exposure, Mountainview CEO Rob Brandt closed the clinic (the facility includes an emergency department, a clinic, and a long-term-care wing) and directed staff who’d been in close contact with the receptionist to get tested and stay home in self-quarantine. The clinic remained closed on Thursday and Friday, and the hospital secured alternate staff to fill in during the ensuing two-week quarantine. The receptionist was the only staff member who tested positive.
As of April 6, that individual remains Meagher County’s only COVID-19-positive patient, which is notable given that Meagher shares a border with Gallatin County, the state’s COVID-19 hotspot, with 116 positive cases — more than one-third of the known infections in the state — as of April 6.
Brandt is working hard to keep Meagher County’s COVID-19 count low. He strongly urges community members to use technology to connect with health care providers, and asks them to call ahead if they anticipate a visit to the clinic or ER. COVID-19 testing is being done outside the hospital, in patients’ vehicles on the ER ramp. The facility’s long-term care and patient rooms have been closed to visitors for some time. (A particularly challenging flu season led staff to take that step Feb. 10, several weeks before Montana recorded its first confirmed COVID-19 infection.) Brandt has also adjusted the hospital’s staffing schedule: for the time being, half the staff works on-site, and the other half works from home to mitigate the risk of an exposure.
“At any given time you could have a large amount of your staff — which is a finite resource, as you can imagine, in our community — wiped out very quickly. If nothing else, just the exposure risk [could lead them] to be quarantined for two weeks.”
Mountainview has even retrofitted a little-used space into living quarters for a Bozeman-based staff nurse to reduce the risk that he’ll bring the virus into White Sulphur Springs from Gallatin County. For the foreseeable future, the nurse is committed to staying in Meagher County, turning his workplace into his temporary home.
Brandt’s plan has an informational component as well. In order to beat back rumors that propagate on social media, he regularly posts YouTube videos, and even hosted a Facebook Live presentation alongside the county’s public health director. It appears to be working; he said his videos have had more views than there are residents in Meagher County.
All of Mountainview’s precautions, though necessary, are eating into its bottom line as clinic visits and the “swing bed” program that’s an integral part of its financial model fall off. The swing bed program, which allows typically older patients to recover from a major medical event or surgery close to home, accounts for about a quarter of Mountainview’s total revenue, Brandt said.
“The swing bed program is absolutely vital to our existence and to our community,” he said.
Like many of the state’s rural communities, White Sulphur Springs trends older than Montana’s more densely populated urban centers. Thirty percent of county residents are 65 or older. According to lifelong resident Zita Caltrider, it’s common for residents to have at least one major health issue — a cancer diagnosis, perhaps, or asthma. This is a population that is particularly vulnerable to the consequences of COVID-19.
Caltrider, who owns Avalanche Basin Outfitters with her husband Doug, said she thinks residents are taking stay-at-home and social distancing directives seriously.
“Everybody in this community has somebody in their life that they’re trying to keep safe,” she said. “We’re doing it for our neighbors.”
Another indicator that White Sulphur Spring residents are taking public health officials’ recommendations to stay home seriously is the increase in demand for Meals on Wheels, which normally drops off one- or two-dozen meals to area seniors on a given day, Brandt said. Last Thursday, that number was closer to 80.
“It was also a very popular menu item” — fried chicken — on Thursday, Brandt said. “But it was a very high count.”
ECONOMIC CORNERSTONES WITH TIGHT MARGINS
Like many rural hospitals, Mountainview Medical Center plays a vital role in its community. Brandt said his organization, which employs 49 full-time-equivalent staff, is the financial cornerstone of White Sulphur Springs, and a regular topic of conversation when locals meet for coffee. It’s also the kind of amenity that can draw people into a community, and keep them there as they age. “People don’t want to move to a small town that doesn’t have health care,” Brandt said.
Montana Hospital Association president and CEO Rich Rasmussen said it’s common for Montana hospitals big and small to be among the largest employers in their communities. “The economic vitality of that community is directly tied to the economic viability of that hospital,” Rasmussen said.
The threat posed by COVID-19 — even in parts of Montana where no case has been confirmed — is destabilizing the financial footing of rural hospitals and undercutting the economic base of the communities that rely on them.
“We estimate that the reduction in state GDP from the reduced use of services [in] hospitals is approximately $96 million a week,” Rasmussen said.
As hospitals forgo elective surgeries, primary care, in-home care, and other services to conserve protective equipment, staffing, and blood supply, they’re eating into their reserves. And some have very limited reserves, Rasmussen said. Twenty-five of Montana’s critical access hospitals, or half of the state’s total count, individually generate less than $10 million in patient revenue annually. That’s less annual revenue than the average Home Depot, he said.
Rasmussen said his office has been fielding questions from member hospitals about how to allocate staff, regulatory compliance in a rapidly changing environment, and securing PPE. In reference to the latter, Rasmussen said the Montana Hospital Association, individual hospitals, and state employees are part of a focused collaborative effort to access equipment. That’s a complicated undertaking in which they’re competing with larger states and the Federal Emergency Management Association for supplies, he said.
At least economically, there have been some promising developments in recent days. The $2 trillion Coronavirus Aid, Relief and Economic Security, or CARES, Act that Congress passed March 27 includes about $117 billion in funding for hospitals nationwide, Rasmussen said, including provisions specifically for rural hospitals. The catch? Treating patients is key to unlocking that funding.
“Those features are really tied to care delivery — you have to have patients in order to be reimbursed for that,” he said.
Even though some economic relief is on the way, it might not arrive quickly enough to keep some hospitals afloat.
“The [CARES Act] will provide support for operating expenses, but the funding may not arrive for months. Many Montana health facilities have an immediate need for lending support,” according to a March 27 press release from Gov. Steve Bullock’s office about a directive he issued to meet rural hospitals’ immediate needs with lending support including bridge financing. “[This directive] will provide low-cost funding to allow facilities to purchase supplies, pay staff, and remain open during this challenging time,” the release said.
SMALL COMMUNITIES, BIG STAFFING CHALLENGES
In addition to current cash-flow issues, many rural hospitals have long struggled with a shortage of health care workers, according to Natalie Claiborne, assistant director of Montana’s Office of Rural Health. All but four of Montana’s 56 counties are classified as medically underserved and health professional shortage areas by the U.S. Department of Health and Human Services.
The workforce shortage is one reason that even a small number of infections in the state’s smaller communities can have a disproportionate impact. If a rural hospital’s medical staff fall ill and are unable to treat patients, “you’re going to be lost,” Claiborne said. “There’s going to be no care for anyone.”
Complicating the issue is the fact that many rural health care workers serve critical roles outside of the hospitals where they work, which can be both a strength and a vulnerability. Theilen said she sees the dynamic at play in many of the rural hospitals where she works.
“Maybe the director of nursing is also the head of emergency medical services and has to be out with the ambulance and the fire [department],” she said. “There’s a lot of crossover in roles and in family [and] living situations.”
Theilen is a jack-of-all-trades herself. She’s been a fire lookout, Grand Canyon trail and river crewmember, bartender, house cleaner, and director of the Montana Book Festival. Working in small communities scattered throughout the state gives her the variety she craves, both in the rotation of settings and in the range of skills she calls upon during any given shift. “There’s some element of the unknown [that’s] compelling, and it keeps me sharp,” she said. “It’s like a really strong cup of coffee.”
By April 4, Theilen’s health was trending upward as the fatigue, mild respiratory symptoms, and body aches that had been bothering her started to lift. That’s the day she received the results of her COVID-19 test. It came back negative.
She said she was still feeling somewhat symptomatic, though. The provider who tested her told her another virus has been going around with symptoms similar to COVID-19 — maybe this other virus was responsible for her fever.
Regardless of whether she has the infection, Theilen said COVID-19 has changed her perspective about her job and given her insight into how she’s wired.
“My job as a nurse almost feels like more of a moral responsibility [now],” she said. “I feel like I have to get better — I have to get better and get back out there and help.”