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Highland Medical Center pushes ahead despite churn
Doctor, nurse to depart
BY ANNE ADAMS • STAFF WRITER
MONTEREY - Doctors and staff seem to come and go with enough frequency at Highland Medical Center to cause patients and supporters concern lately about its stability, but the small rural clinic continues to thrive in the face of ongoing personnel challenges.
The last few years have seen changes in key roles - a situation that may be here to stay. Most recently, current physician Dr. George Damewood will leave when his contract expires in February; long-time nurse Becky Dever has told the HMC board she intends to resign; and after being close to securing a permanent executive director in Kim Billingsley, she did not accept the position and the search for a permanent director is still on.
HMC board president Bill Ellenburg remains confident HMC will work through its issues and maintain its high level of medical care in the community, however. In the last couple of years, HMC has been more financially solid than ever, thanks in part to a federal support that provides some $310,000 of its $950,000 annual budget.
"The grant's been renewed; we've had an increase in staff; we bought the adjacent property (a small home near the center) that we can use as an incentive for new employees to live … We've done very well in several areas, but there has been some personnel turmoil the last couple of years that has caused some people to solidify their intentions, which results in change," Ellenburg said.
In addition to the most recent personnel moves, former HMC executive director Polly Newlon resigned last March and then stayed through mid-October, a couple of months shy of a three-year stint at the helm; and Dr. Daniel Freed resigned at the end of his four-year contract.
"We lose some and gain some, and there's been enough turbulence," Ellenburg said. "But we have an active board, a staff that really cares, and continued financial support. There's plenty of potential for 'new brooms sweeping clean,' and we hope to build a new team and find better ways to move ahead."
Staff turnover
Billingsley, who served until recently as HMC's chief financial officer, had applied for the executive director's position after Newlon resigned. She was offered the job, but according to Ellenburg, she chose not to accept the job.
Billingsley has resigned from her post at the center, though is serving as interim director a few more weeks under a temporary contract. Billingsley said she and the board did not agree on terms, but she wanted to help the center temporarily after Newlon left in October. Beyond that, she has no immediate plans for other employment other than to continue her tax and accounting business in Highland, she said.
Ellenburg said HMC is in a "very active" search for a director to replace Newlon. "We have several qualified applicants on the list that have already been approved," he said.
Potential candidates are sifted through the federal grant agency according to regulations. "We're trying now to finish the process so we can get to interviews, offers and negotiations," he said.
He expects it will be a few months before a director is hired.
Damewood, who was hired to replace Freed, will leave when his contract is up in February. The search for a new doctor has been ongoing for several months, and there is one candidate who is seriously considering a move here in late spring, Ellenburg said. The doctor has visited Highland, and negotiations are moving forward, but the candidate has not yet committed to moving here, and if he does, it will likely be a few more months down the road.
Damewood said he would rather have left when he was ready, but is not upset that HMC's board chose not to renew his contract. "I know there's been a lot of controversy about my leaving, but Highland County has a great bunch of people and the doctors have been great," he said. "There will always be turnover. I was recruited but I knew in the long-term there was no promise of moving on. I have two elderly parents who take some time, a daughter graduating high school this year, and more of a pull to be elsewhere."
HMC, he added, is a "great place with great potential. I have confidence in Bill; it's getting back in the right direction … I don't feel like I'm being forced out. The board will figure out how to get a good new director, and new doctor. I don't feel too bad about it."
Ellenburg offered no particular reason for the board's decision not to keep Damewood at HMC. "I'm making no inference at all about his qualifications; his competence (as a doctor) has never been in question and he's always had a number of laudatory comments," he stressed.
"I knew I'd have to move on eventually," Damewood added. "But I love Highland and Bath and I plan on keeping my residence in Highland County and possibly being available to help working with rescue squads or clubs. I plan to keep at least one foot in Highland County."
Damewood has been searching for other employment for about six months. He will remain at HMC until the end of February.
Dever, who has been a familiar face for patients at HMC for more than a decade, has given a "notice of intent" to leave, Ellenburg said. "She's put no timeline on that, but she's seeking other employment."
Dever, a supervising nurse, was voted "Nurse of the Year" last year by the Virginia Primary Care Association at its annual conference last May. She was a driving force behind HMC's founding and its early operations in 1996.
Newlon said she had just reached the point where "I wasn't able to do what I needed to do. The conditions were not such that I could pull it off … if you cannot get people to buy into logic and reality, you cannot be effective, and I was not able to make things happen."
But she, too, is confident HMC will find a way to achieve its goals. "I want to see them do well, and I think they can. That center is not like the rest in Virginia. We have so many fewer problems," she said, noting more urban health centers wrestle day to day with huge issues like AIDS patients, drug problems, and homeless patients. "We don't have anywhere near that kind of thing," she said. "If we let little stuff bring (HMC) down, we deserve it. But we should be able to work everything out. People have to give it a chance."
HMC could continue to have staff turnover like this in the foreseeable future. "It's just the norm for these clinics," Ellenburg said.
Damewood said HMC needs to concentrate on clinic services. "It's not about the doctors," he said. "This is a rural, family practice that can offer services like pediatrics, orthopedics, and things across the board. The doctor is on call 24 hours a day, 365 days a year. You must see people after hours, but it's not a problem. It's not a big deal. You just take the calls; it's easy. And it's fun, it's nice to be appreciated for that."
In the long term, Damewood said, "the doctor turnover will continue because we're production-based, but we only have 2,400 people in the county."
Fortunately, he added, HMC is subsidized and can continue to give free care to patients in need. It can be a win-win situation for a physician, he said. "You find doctors who need to get their tuition paid off, but as for continuity, that day may be over. That economic model may be over. But we have a great building, great structure, and a great staff. I'm very positive about the future."
Part of the turnover may be associated with the federal grant providing nearly a third of HMC's budget. That grant has been renewed for another five years, through 2011, but it comes with stringent requirements that require a lot of administration.
"It's reviewed every year," Ellenburg said. "Every year we have to re-justify having the grant, but it has allowed us to pay for more medical providers, more medical staff, and more administrators, so we are also creating jobs here."
Billingsley said the grant requirements put pressure on the medical staff to meet certain expectations. Some of the strings attached are centered on productivity - the number of patients per year each medical provider should see. "We have to constantly monitor (medical providers') schedules to meet that number, and they have to fit in more patients a day."
Also, Billingsley explained, federal grants like the one HMC is using are typically modeled on an urban environment, and getting patients in and out quickly.
"But it's not just the numbers," she added. "There are certain promunity grams we have to participate in, and provide for patients … there's a lot of pressure for the reporting requirements."
Newlon agrees. "That's how community health centers are," she said. "They all have a great deal of difficulty recruiting and retaining medical staff."
There's a big difference between community health centers like HMC and private practices, she added. "Most medical practices on the planet are private, run by doctors to make money. It's a totally different business model."
When HMC first started more than 10 years ago, it was a nonprofit that didn't yet operate as a federally defined community health care center eligible for grant money. "They were going on whatever they could beg, borrow or steal," Newlon said. "But when they became qualified as a community health center, they had to jump through a lot of hoops."
As such, she explained, HMC's medical staff will always work as employees of the center, not selfemployed physicians that can make whatever choices they want for their practice. "It's a really different relationship," Newlon said.
HMC's salaries and benefits are competitive among other similar health centers, "but we're never going to compete with what doctors make in private practice," Newlon said.
The structure is typical of such centers - a board creating and enforcing policy, an executive director managing things day to day, and doctors and other staff in place for services. "But to make it work like a well-oiled machine is difficult, and it's not the kind of thing a lot of clinical people like," Newlon said.
As for whether the grant money HMC relies on makes it worth the extra effort, Billingsley said, "I don't think we've fully determined that yet. It takes a long time to make all the changes, and we're so isolated we can't bring in more patients. As the years go by, we will get more efficient at meeting these requirements, and we expect a good executive director to do that."
Damewood said, "I'm not the grant person so I'm not sure about those difficulties … but I know we need to concentrate on the services we provide. We had an excellent doctor who superceded me (Freed) and he was also an optometrist providing that service. I know there's some pressure for numbers, but we need to keep the grant."
That money, he said, allows HMC to give a lot of free care, free drugs, and free transportation. "No one is being turned away," he stressed.
"Despite having more turnover in both medical and administrative staff than expected," Billingsley added, "I believe that we have fulfilled our mission to provide quality health care to this community."
Newlon, too, said it's not all about how many patients a provider sees. "There are times when it's absolutely appropriate to spend an hour and a half with (a patient), but on average, you can't. But if you push those numbers enough, you're no longer giving quality health care. People will argue, justifiably, that health care (nationwide) is going down the tubes for that reason. But community health centers really are not as bad as many private practices. If you're in your own private practice, you're the king. If the doctor wants to spend more time with people, he can. But it's different for com- health centers. There are about 1,000 of them across the country (like HMC) in the same boat. What's unique to us is the history of Highland County," Newlon said.
For 50 years, Highland was served almost single-handedly by one doctor. Until his retirement nearly five years ago, Dr. Thaine Billingsley was the primary caregiver here, and as such, patients developed a deep, long-term, personal relationship with him.
"People need to understand in Highland County it's never going to be that way again," Newlon said. Although, she believes, in about 10 years more private practices could become established in the area. "But it will be a new model," she added.
"The nightmare scenario is one physician who has to see everybody, and HMC has to do that now. It has to be everything to everybody. People need to let go of the notion it's like a private practice. It's not … these doctors are not like your minister, and people will have to get used to the idea (HMC) will always have turnover. You're going to find that everywhere."
Positive changes
Aside from creating new jobs and financial stability, Ellenburg is particularly excited about a new program spearheaded by Dr. Kim Bird, HMC's medical director. "She's working with patients to improve their health in a proactive, not reactive, way," he said. "This comes at the state level with the Virginia Community Health Care Association initiative (formerly Virginia Primary Care Association), and it provides close monitoring of patients," he said. "We are educating and informing selected patients to steer them to better health."
Bird said support for the program comes through the state from a federal initiative, the Health Disparities Collaborative. "The federal Department of Health and Human Resources has been doing this for years with community health centers," she explained. "They gave Virginia money for its state-based program, and it targets diseases one at a time."
There are several subsections to the program, and HMC is now focused on cardiovascular problems, including high blood pressure, high cholesterol, and heart disease. "We look at the process of how they're taken care of," she said, "and the delivery of care. We look at alternative ways people receive medical care and get them more involved."
HMC now has a blood pressure cuff in its waiting room, for example, so patients can drop by and monitor themselves. There are also scales in the bathrooms where people can compare their weight with a chart showing what their weight should be.
"We are talking to patients about how to better their own health," Bird said. Patients can get a chart to show what their blood pressure or cholesterol is, with a goal next to it, and medical providers give them specific examples of how they can reach those goals, like getting 30 minutes of exercise or using a low-salt diet. "The form becomes part of their chart, and they know where they are," she added. "It's more concrete. We give them nutrition information, we talk to them … we look at the collaborative measures not individually but as a total group, and over time, we can see the number of people getting their pressure under control. It really improves the markers for care. It's encouraging, because we see it really makes a difference, although there is a lot of data collection involved, but it's fun to think outside the box. We've been doing this program since last summer, starting with a subset of people."
Over time, the group of folks involved will increase so that eventually, everyone who comes into the clinic will be involved. "And as the group grows larger, all the other providers will be included. We'll go onto to other issues like asthma, depression, or diabetes," Bird said.
Ellenburg also noted HMC's improvements in its billing system. The center spent a lot of money on a new system, Ellenburg said. "Our billing was behind by two years," he said, "and now we've been able to catch that up."
Furthermore, the medical center has made progress in administering its grant support, improved its statistical data gathering, increased its focus on the medically underserved population, and added professional staff to fill its needs in other areas.
Support still needed
HMC continues to rely heavily on private donations for more than two-thirds of its budget support. There is a separate foundation overseeing about $150,000 in seed money that's invested. The interest is then used strictly for capital needs, which the grant usually doesn't cover. Ellenburg said he'd like to see that principal amount increased through donations over time.
HMC's wish list also includes new waiting room furniture, and a high-end defibrillator.
Down the road, long-term goals include a wellness center, physical therapist, dental services and other services HMC has kept on its todo list.
The idea for a wellness center surfaced in tandem with the county's pursuit of an overall recreation complex and swimming pool on the school campus, a project coordinated by the county recreation commission. "We hope to get more involved and participate with them on this," Ellenburg said. "It depends on how things shake down with a new doctor and a new director."
Electronic record keeping is another change HMC could field before too long. It involves keeping patient records digitally, as opposed to cumbersome paper files, and having medical providers use a sort of electronic tablet for notes and recommendations - something used increasingly nationwide.
"We're sort of being forced to do it, but the state is endorsing it," Ellenburg said. He estimates the new system could cost as much as $30,000, but that some chunk of the expense might be provided through grants.
Bird believes such a system could be useful, particularly for things like generating reminders for patients on check-ups and preventative care. "And it will be nice to pull information quickly for patients, like dietary brochures," she said.
Writing prescriptions would also be a time-saver. By generating those electronically, there will be fewer issues with unreadable handwriting or lost prescription slips. "And maybe at some point, patients would even be able to schedule their own appointments," she added.
Wanted: Dentist, therapist
HMC has been searching for a part-time dentist ever since it set up facilities to accommodate one a couple of years ago, with little success.
Ellenburg said negotiations with potential dentists have been long and drawn out. "We just can't offer what they (earn) in the big world," he said. "There are 800 community health centers like us and our salary scales are comparable to the rest of them, (but) we can't compete (with private practice earnings). We have to find someone willing to sacrifice, and be dedicated."
Damewood said a dentist will definitely be hard to come by. "Dental care is expensive," he said. "There's lots of overhead … They need to find someone maybe close to retirement."
Securing a physical therapist has also been a challenge for several years. After therapist Nancy Veasey left the center, HMC entered into an arrangement with Bath Community Hospital for PT services. "We even lowered the rent (on the facility) but they (BCH) still pulled out." BCH opened a new facility in Bacova, and Ellenburg said, "At first they said they'd transport our patients there. We still have a few, but most of them have fallen off."
There are liability issues with a rental agreement as well. "There are a lot of pros and cons, but it's not a dead issue," Ellenburg said. "Maybe we can start something with the new (recreation complex) for physical therapy."
Damewood agrees. "We have an incredible facility here, and physical therapy is a big need," he stressed.
Long-term goals
Bird noted HMC is also interested in getting a weight loss group up and running, though the idea had stalled out with some of the staff turnover.
Damewood believes the center should step up its involvement in large, community events here like the Mountain Mama bike challenge, the annual fair, and the maple festival. "We need to get around during these things and be involved. Let's help out," he said.
Patient education is something Damewood would like to see the center emphasize in a broader fashion. "We should be the lead people on this," he said, adding the center should stay active in promoting health through the media and getting specialists to share information.
He also believes HMC should be in the forefront when it comes to emergency preparedness plans, something he says Bath County has done well. "The clinic has a lot to provide, and there's no plan for the county," he said. "I've been on the committee for the county and it has never met. Where is the plan?" He says HMC should get better integrated with the county rescue squad with a higher level of cooperation. "It's going to be a battle, but we have got the expertise, we've got a great nursing staff."
"We continue to ask ourselves, and we want to hear from the community, what kind of services we should be providing," Ellenburg said. "We'd like to know what (residents) think we should be doing. Obviously we can't become an emergency room, which is something a lot of people complain about, but it's such a specialty service, and it's expensive. Our doctors must be available 24 hours a day on call, but lots complain we can't provide emergency care in the middle of the night. But we do a lot of on-the-scene care when necessary."
Bird, too, is positive about the future. "There is always some anxiety when things are changing, but Highland Medical Center will survive. It's an important service to the community, and one way or another; things always have a way of working themselves out. I have faith that whatever happens will be for the best, and it will be just fine."
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