- [Narrator] Coming up on ncIMPACT, Access to healthcare is an issue for many in rural North Carolina.

We'll find out how some communities are getting creative in providing high quality care.

- [Narrator] ncIMPACT is a PBS North Carolina Production in Association with the University of North Carolina School of Government.

Funding for ncIMPACT is made possible by... - [Narrator] Changing the course of people's lives.

That's the impact UNC Health and the UNC School of Medicine work to deliver every day.

Our 40,000 team members across the state of North Carolina are committed to caring for you, our patients and communities, as well as educating the next generation of healthcare professionals.

Individually, we can do a little, but collectively we can do a lot to create impact.

- Welcome to ncIMPACT, I'm Anita Brown-Graham.

Lots of hospitals and rural communities all across the country have closed our doors in recent years.

North Carolina ranks third nationwide in these rural hospital closures.

NcIMPACT's David Hurst visits one of our rural communities that has been left without a hospital.

- Anita, Belhaven is a waterfront town in Beaufort County.

Pungo Hospital was shut down there in 2014 and left residence without emergency room services.

Town leaders say in an emergency, minutes matter and the hospital closure has been devastating for their community.

- 'Cause of the main highways you can't walk.

- [Narrator] Former Belhaven Mayor Adam O'Neal fought hard to keep the hospital of his community.

- I've got a bunch of stories about that.

- [Narrator] He even led two marches to Washington DC to protest the hospital closure.

- So I thought if enough people saw what was happening here and saw the documents and saw what was happening, that somebody would help us.

That was my belief at that time.

So this is the original hospital.

- [Narrator] But in 2014, Vidant Pungo Hospital closed its doors.

The hospital closure affected not just those in Belhaven, but also those who live in surrounding communities.

- Between Washington, North Carolina and Nags Head, North Carolina is 130 miles.

So there's a 130 mile gap without an emergency room in East North Carolina.

That would be almost like no hospital between Raleigh and Wilmington, you see?

So it's a big deal.

- [Narrator] O'Neal says the hospital closure also put more than 100 people out of work and is costing the community about $17 million of economic impact a year.

- And when you're talking about a town of 1600 people, when you take $17 million of economics out of the community of money flow, it's devastating.

- [Narrator] Vidant Health says they closed the hospital in part because of the condition of the facility, its location in a flood zone, and it was losing money.

The closure is part of a nationwide trend of rural hospitals shutting down mainly because they lose money delivering services to patients.

- It's sad to think the people that helped build this community, helped build this county, helped build this area are the ones that are having to suffer now because of the lack of healthcare.

- [Narrator] Bill Booth was one of the community leaders at the front of the fight to save the hospital in Belhaven.

He says those in rural communities already face numerous health disparities and the closure of rural hospitals make those residents even more vulnerable.

- Because of that, like we said back then, people have died and they're still dying.

- There's us walking... - [Narrator] For O'Neal, he wants to continue to shed light on the trend of rural hospitals closing and highlight the cost on communities and those who live there.

- 'Cause the silent cost of these rural hospitals closing is that people are sicker because they don't get attention to a stroke in time.

They don't get attention to a heart attack in time.

So the cost of not having these rural hospitals is extreme.

- To help fill the healthcare gaps in Belhaven, Vidant Health did open a multi-specialty clinic.

However, the former mayor says they do not offer emergency services and the staffing and equipment are limited.

- David, thanks so much for that story.

Joining me now is George Pink.

George is the Deputy Director of the Rural Health Research Program at UNC Chapel Hill.

George, thank you for being with us.

You've done a lot of research about hospital closures in North Carolina.

Help our viewers understand what's causing these hospitals to need to close their doors.

- Thank you, Anita.

We've studied about 186 rural hospital closure since 2005.

When we look at the newspaper reports, the media reports of why they closed, we generally find three categories of reasons.

The first is market reasons.

They tend to be located in areas which have got declining populations, high proportions of uninsured, underinsured, high dependence on Medicare and Medicaid, and in some cases competitive pressures.

The second category are what we call hospital factors.

The buildings are old, the technology is outdated, they are having trouble recruiting physicians, they're having trouble finding nurses, and sometimes there's fraud and safety concerns.

The third category, which tends to be the most important category, is the financial category.

These hospitals tend to be money losing organizations for a long period of time.

It doesn't just happen, say we lost money last year, let's close.

Typically these hospitals have have lost money for 5, 10, 15 years.

They draw down their reserves, they sell off their assets, they max out their credit, and then they just run out of options, so they go into bankruptcy and close.

- That's really helpful, listening to those three categories, it's clear that sometimes this is symptomatic of larger challenges in a community.

So help us understand, outside of not having easy access to a hospital, what are other challenges that people who live in these rural communities face in trying to access quality healthcare?

- Well, they face many challenges.

When all of us live in a semi-urban or urban area.

When we have to go to the doctor, what do we do?

Well, we can drive, we have a taxi, we have Uber, we have a bus.

Sometimes we can have a train, if we live in Charlotte, we can take a mass transit of some sort.

Someone who lives in a very rural area, they've got one option and that's to drive.

And driving in an urban area is not a big deal.

But if you're old, if you're poor, if you're disabled, driving five, 10 miles in the country is a real barrier to accessing healthcare.

- George, stick with us.

We'll come back with lots of questions for you later.

Primary care physicians are in short supply everywhere but the shortage of physicians is even worse in rural communities.

NcIMPACT's Sloane Heffernan shows us a residency program that puts new doctors on a track to serve people in rural areas.

- This innovative program is helping some of the most vulnerable people in our state receive high quality medical care.

- Can you take some deep breaths for me?

- [Narrator] Rashieda Pugh says she's always wanted to be a doctor.

She says she was eight years old when she made the decision after seeing what her family went through.

- I wanna give back to the communities that I grew up in, coming from a low income community, not really having access to healthcare.

- [Narrator] Dr. Pugh is part of the UNC Family Medicine Residency Rural Track Program at Prospect Hill Community Health.

She will spend three years training at this federally qualified health center operated through Piedmont Health Services.

- We were running out of... - [Narrator] The center, which is the oldest community health center in the state, serves the underserved and under-resourced in rural Caswell County.

- To me the care is really important for this demographic because it's really hard for these people to access healthcare in kind of the traditional senses.

- I'm gonna start on your shoulder first.

- [Narrator] Dr. Caroline Robert says many patients who come here are uninsured, undocumented, and don't have money for expensive treatments.

- Somebody might come in, they might have concern for a pneumonia for example.

And typically we would order a chest X-ray.

We would use kind of the various tools that we have in our toolkit, but we really have to be comfortable as physicians practicing to kind of the utmost of our license without these extra tools 'cause our patients might not be able to travel 45 minutes to get an X-ray.

- But I mean there's no pain there at all.

- [Narrator] The Rural Residency track was created about a decade ago to attract doctors in rural areas, As part of the renowned UNC Family Medicine Residency Program, the rural track has become highly competitive.

- We attract residents from all over the United States of America, including people from rural spaces in North Carolina.

And so we gather residents with that passion and that desire to learn.

- [Narrator] Research shows that those who train in rural areas are far more likely to practice in rural areas.

- It's an exciting place to learn medicine in a community-based setting.

- [Narrator] Brian Toomey, CEO of Piedmont Health says the partnership with UNC and Community Health centers is ideal for North Carolina.

Toomey and others would like to see this model used across the country.

- It's a way to connect and feel like you've really made the difference in the lives of not just the patient in front of you, but their families and generations around you.

- [Narrator] It is everything Dr. Pugh says she dreamed about as a little girl.

- It's about bringing happiness and bringing health equity to marginalized communities and that was always my goal.

- The Siler City Community Health Center is the newest site for the rural track program.

Residents began seeing patients there in 2019.

At that time, it was estimated that more than a quarter of the lived below the poverty level.

- Thank you Sloane.

Joining me now is Adam Linker.

Adam is the Vice President of Programs at the Kate B. Reynolds Charitable Trust.

Adam, the challenges are real and yet, as we just saw in that segment, there are solutions that are reason to have hope.

Maybe you could start by sharing some more reasons to be optimistic about our ability to serve the healthcare needs of those in our rural communities.

And it's okay if you show off a bit and tell us some things your own organization is doing to bring high quality healthcare to rural communities.

- Sure, thanks for having me Anita.

Absolutely, rural communities are vibrant, wonderful places to live and so I think there's a lot of potential in North Carolina.

We also do have a lot of great public health departments, a lot of great health systems that are providing great access to care in many parts of the state.

I think there's new programs like this that you spotlighted.

There's also a new residency program in the southeastern part of the state that Cape Fear and Campbell through their medical school is ramping up in serving some of those rural areas like Bladen, Columbus, Robeson counties.

So I think there is certainly reason for optimism, but I think we also have to have the policies that support these vibrant communities and continue to develop them to make them great places to live.

- Hmm, so talk to us a little bit about some ways that rural community leaders can themselves create and invest in systems that increase access to healthcare.

- Yes, so I do think that there are different programs that many local leaders are instituting just things like community paramedicine, things that are extending the reach of healthcare, telemedicine into more rural regions but I also think investment is key.

I think we sometimes have political leaders or elected officials who mostly want to brag about tax cuts and how they've cut funding.

But we really need at every level federal, state, and local levels investments in community.

Because what we end up hearing oftentimes is doctors may and psychiatrists may want to practice in a rural area until they have kids and then they might say, "Well this school system is very racially segregated and underfunded and so I don't know if I want to stay in this area if we're not gonna invest in public education."

- Thank you Adam.

In rural counties across the state, nearly 27% of people have no health insurance.

The reasons for this differ, but for many, the lack of a hospital nearby means residents have few options.

NcIMPACT's Evan Howell visits one community where healthcare comes to them and offers the services so many residents need.

- A lot of people are surprised by... - [Narrator] Growing up in a small knit community, Patricia Gilley has always taken care of her neighbors.

- Everybody deserves healthcare no matter what walk of life, where you're from, what you're experiencing.

- Do you have a doctor name that you go to?

- No.

- [Narrator] Gilley's part of the Congregational and Community Nurse Program with Cone Health.

They operate a fleet of vehicles that bring screening and acute care services to remote sites across Rockingham County, including here near downtown Mayodan.

- And a lot of people just don't know where to turn.

They don't know they've gone place to place to tell their story but they don't ever feel really listened to.

- [Narrator] The four county program helps fill gaps in rural communities that lack access to healthcare.

- We had seen for many years in the communities that we serve significant social determinants of health.

And these barriers have created situations where the patients do not have access to the right care.

They don't even know they have conditions.

- [Narrator] And often in these rural communities, the nurses represent a needed friend to those who may not know where to go.

- I had nothing, I had nothing but the two feet that I walked on and I needed healthcare and I needed somebody in my life that could help me take care and show me that love and compassion which I today pass on because of this.

- A lot of your blood... - [Narrator] After 25 years in a hospital setting, Gilley's glad she's now out on the road with a mobile program.

She says she does it to give back to the very families she grew up with years ago.

- Your doctor in Lawson.

- Just sitting down and just listening to that person and walking alongside of them through whatever journey they're going through, help connecting them to any kind of resources they need.

- [Narrator] Cone Health officials say having local churches as partners strengthens trust in the community and that forms the backbone of the program, a relationship they believe will only get stronger.

For ncIMPACT, I'm Evan Howell.

- Thank you so much Evan.

Let's bring back our experts.

And joining us for ncIMPACT Roundtable is Lisa Harrison.

Lisa is the director of the Grandville Vance District Health Department.

Lisa, let's start with you if I might.

Every community could use more people like Nurse Gilley.

What are some ways rural community leaders can strengthen the healthcare workforce, attracting or growing this kind of talent?

- That's a great question, Anita.

I think in North Carolina, we're so fortunate that we have a public health system that has a health department access point in every county in North Carolina and nurses are certainly the largest portion of our public health workforce.

So we are always collaborating with our hospital systems, our schools, our churches, making sure that we're coming up with new and creative ways to address the needs like those we just heard.

Our public health directors in our communities are our chief health strategists.

So those collaborations and opportunities for collective impact to get the work done is really, really critical.

- I'm just saying, the words, "Collective impact" give me personal joy.

So let's talk about collective impact for a moment.

We've heard of challenges that may seem adjacent to the critical issues in healthcare, challenges such as transportation or maybe financial viability.

How do communities come together in this kind of collective impact model to ensure that they're addressing the myriad issues that might be causing people not to be able to access healthcare?

- Yeah, we just finished a community health assessment process and in that process, the focus groups revealed that when it comes to accessing healthcare, you're exactly right.

The perception or reality of affordability of that care is really a barrier for a lot of people.

So certainly you're right, the transportation and the traditional ways we think about accessing care still exist.

But that collective impact model helps us communicate across rural communities about what's available, about where you can access care at a lower cost or like in a local health department.

50% of our local health departments across North Carolina offer full scale primary care at a sliding fee scale.

So like our community health centers and free clinics, public health has opportunities that might be more affordable for our rural residents.

And we want to make sure that all of our partners and communities know this.

- Thank you.

Adam, I've noticed you nodding in affirmation here.

Kate B. Reynolds has funded community coalitions to develop something akin to a collective impact model.

Tell us a little bit about that.

- Sure, I was gonna say two things.

One is that we have these social determinants that we want to address like transportation, food, access, and I think sometimes we bring stakeholders together but don't always engage the folks most impacted by the problem.

And the folks who suffer from lack of transportation often know the barriers that communities face when we are trying to fix the transportation system.

They know the barriers to the grocery store or affording food or enrolling in WIC and SNAP.

And so they can really be critical partners in driving that process and really driving that change.

And so I think one thing we think about as we're trying to support some of the community collaboratives and coalitions to work on these issues is making sure that the people most impacted by the problems have the resources they need to be at those tables 'cause the rest of us get paid to be in meetings.

A lot of the folks who are most impacted by the social determinants are not paid in their day jobs to be at meetings at the health department or at the hospital.

And so we wanna make sure that they have the resources to be at those tables.

I think one other kind of interesting thing is that the state has a large scale Medicaid pilot as well called the Healthy Opportunities Pilots and there are three sites in North Carolina.

And those pilots are getting Medicaid funding to pay for things like food and transportation.

And so that could be a model moving forward if that pilot is successful to roll out to other rural areas of the state.

- So George, we're gonna learn a lot from the pilot program Adam just mentioned.

We also have an opportunity to learn from some existing programs.

So you sit on the board of Piedmont Health Service which we saw earlier featured in the episode.

Can this kind of community health center model work for all rural communities?

And if not, why not?

- Well, all rural communities, there's one thing I've learned about working in rural health for 20 years is that, there's no two rural communities that are exactly the same.

There's a lot of variation in different parts of rural America.

I think FQHCs and community health centers have been remarkably successful at addressing the local needs and reflecting the priorities of the local populations.

And I personally am a huge fan and advocate of these types of organizations because they're so locally driven.

Communities that have got high degrees of poverty, they've got a high proportion of underserved populations, they're gonna have different needs than a community that's perhaps in the mountains that's got very different kinds of socioeconomic or social determinants of health issues as well.

So FQHCs are not a one size fit all model.

They are very flexible and adaptable, meeting local needs.

Can they meet all the needs?

No, they are primary care clinics.

They don't do specialty care within limits.

They do some limited specialty care, but generally speaking, they're primary care only.

We certainly need better access to specialist care by the primary care community.

And of course the primary, FQHCs are limited in number.

I mean, not every community has got one.

- George, I appreciate that answer and I would've given a similar answer if somebody had asked me a dumb question like "Would this be a silver bullet for all rural communities?"

So thank you for that.

So we've talked a lot about prevention and routine care and new models for delivering on that and overcoming some of the challenges.

I wanna just throw on the table for our last question, but what are we going to do about hospital access to people who now have to drive two hours for acute care?

Any one of you, take at it.

- Well, I'll jump in.

I was certainly very involved in the Belhaven Hospital work in Beaufort County and folks in Hyde County and in Aurora on the other side of the river are in desperate straits now because of that.

And one of the primary things that Vidant said at the time that they closed the hospital was that not having Medicaid expansion made the hospital not viable economically.

And so I think that's a critical next step for the state.

As I was talking about investments and funding, we need investments in public health.

We need investments in FQHCs at the federal and state level but we also need Medicaid expansion and that is available at the federal level.

The state will benefit tremendously from it.

And we've now heard, both the House and the Senate Republican leaders say that it's critically important for the state.

We know that the Governor has said he thinks it's critically important for the state.

So now we just need elected officials to come together and make it happen so that we don't lose more hospitals and more health centers and other access points that are critical for rural areas.

- George, Adam, Lisa, thank you for the really important work each of you is doing for communities all across the state.

We are blessed to have you.

- [Narrator] We want you to tell us what your community is doing or how we can help you.

You can email us at ncimpact@unc.edu or send a message on Twitter or Facebook and be sure to join us every Friday night at 7:30 on PBS North Carolina for new episodes of ncIMPACT.

Coming up on ncIMPACT, students in rural communities sometimes lack opportunities to gain skills that many jobs today require.

We'll explore solutions to bring STEM education to rural schools.

[upbeat music] ♪ [upbeat music] ♪ - [Narrator] NcIMPACT is a PBS North Carolina production in Association with the University of North Carolina School of Government.

Funding for ncIMPACT is made possible by... - [Narrator] Changing the course of people's lives.

That's the impact UNC Health and the UNC School of Medicine work to deliver every day.

Our 40,000 team members across the state of North Carolina are committed to caring for you, our patients and communities as well as educating the next generation of healthcare professionals.

Individually we can do a little but collectively, we can do a lot to create impact.