2018 REHPS Scott Dingus

Final Thoughts:

Fall River Health Services was a fantastic location to learn about rural health through the REHPS program. The diversity of problems that rural healthcare professionals must tackle daily is very appealing to a healthcare student, like myself. Just because a hospital is rural does not mean that the facility cannot keep up with advances in care that larger facilities are implementing. My favorite aspect of the REHPS program was interprofessional activities, which are hard to incorporate into school programs because the students are not in the same location. Smaller hospitals are great settings for heavy interprofessional collaboration because all other disciplines are right down the hall and always easily accessible. In all, my time at Fall River Health Services showed me the many benefits to working in a rural setting as well as the enjoyable challenges that rural health brings to all healthcare professionals.

In all, I had a fantastic time during my REHPS experience in Hot Springs. I learned about many of the challenges that rural healthcare professionals face, including staffing, ordering, appointment retention, disaster preparedness and much, much more. I also found an overwhelming amount of positive aspects of rural healthcare, including diversity in daily tasks, personal connections with patients, close interdisciplinary teamwork and many other benefits. I also really enjoyed the agricultural and patriotic backgrounds that many of the patients have around Hot Springs. I have seen just how crucial rural healthcare is.

Week One:

Fall River Health Services is a very unique rural healthcare system, mostly because of the independence and community influence tied to the facility. Fall River Health Services includes a 25 bed Critical Access Hospital, Emergency Room that runs 24 hours, 48 bed nursing home and a health clinic that welcomes walk-ins. The hospital was set to close around the transition into the 21st century and the community rallied to keep the hospital open to serve the community. The healthcare team takes great pride in seeing how the community benefits from having the rural healthcare facility located in Hot Springs. The hospital is one of the only facilities not directly connected to Regional Health in the area. I was very impressed when hearing the passion that all workers have at the facility being an independent hospital receiving no financial aid except discounts related to being a critical access hospital.

The Sunday before Azra and I started at the hospital, we were given a tour of the house that we would be staying in while in Hot Springs. The house was previously owned by an involved community member and has many relics from the community, including many paintings and items from historic locations in Hot Springs. The house is currently used to house workers that would otherwise commute to Hot Springs and students learning at the hospital. The leadership at the hospital is always ready to accommodate housing needs of students and professionals, which can be a challenge in the rural setting.

The first day we were taken to the pharmacy and introduced to the friendly staff. The pharmacy hosts approximately 6 pharmacy students a year as well as REHPS students. One of the pharmacy technicians gave us a tour of the hospital as well as the attached nursing home. The staff was very friendly and stopped what they were doing to introduce themselves. The rest of the day we met with the business office, the physical therapy manager, the human resources manager and the operating room nurse. Many of the managers discussed that one of the main challenges that rural hospitals face is finding and keeping personnel. Many job openings stay open because people have negative stigmas about rural healthcare. Because of this, many personnel take over responsibilities not in their area of expertise to give patients the best care possible. I was very interested in physical therapy and occupational therapy because most patients are referred to these personnel after hospitalization. Many of the patients continue to come back to the facility after hospitalizations to continue their therapy and return to their normal functioning status. I have not been exposed to the physical therapy process in the hospital, and most patients in larger healthcare organizations are not given therapy in the same healthcare facility, which is a convenience in this rural facility. Peggy, the OR nurse, discussed how the procedures that are performed at the Fall River hospital are limited, so the OR area is also used for specialists commuting to the area to see patients.

The second day we met with supply, IT, the CFO, Lab, housekeeping, the CEO, the psychiatrist, the ER nurses, radiology, ultrasound and environmental management. Keeping a continuous supply of medical equipment and IV solutions is difficult in a rural setting. Small hospitals have to keep a larger inventory to make sure that the hospital does not run out of these items in the event of a shortage. The normal saline shortage caused by the natural disaster in Puerto Rico hit the facility and alternative normal saline had to be sought due to this shortage. This really showed me that in these situations, smaller facilities can be affected the most because of their location and limited access to the medications. If Fall River needs an item, the only facility within the region that could supply the item in a shortage is Rapid City Regional Hospital, which already has many other small facilities to supply. Even though Fall River Hospital is rural, they keep up in the technology department. Fall River is transitioning to EPIC software in the fall, just like many larger facilities in the region. The hospital is a critical access hospital and is apart of the 340B program, but the hospital does not receive other funding. This is due to the hospital being proactive in budgeting and maintaining many services that most rural hospitals do not have. The housekeeping staff at the hospital has had trouble keeping staff, partially due to the low population in the area. Fall River has a psychologist and psychiatrist on staff, which is very unique to a rural setting. Fall River has the only psychiatrist in the area and he stays very busy servicing all the facilities in the area as well as referrals from Rapid City. Since I was paired with a clinical psychology student, I was able to see the non-pharmacological treatment in mental disorders that most pharmacy students are not exposed to. Since Hot Springs is home to the State Veterans Home as well as the Hot Springs VA campus, many mental disorders that staff treat are military-related. The mental health services that Fall River Hospital offers are unparalleled to most rural settings by having so many professionals in mental health located in Hot Springs. The ER at the hospital is also a benefit to be able to treat these cases on site. One challenge that the ER continually addresses because of it’s rural setting is transportation of patients to larger facilities by ambulance or helicopter. These services are very expensive and can cost up to $50,000 dollars. The hospital has addressed this by advertising for insurance to cover helicopter transport to other facilities. The hospital offers X-Ray services as well as ultrasound. The X-Rays are read by staff at Rapid City Regional Hospital and sent back with results. This helps patients by not having to travel to other facilities to receive these services. The ultrasound specialist allowed us to practice on ourselves and show us how to see carotid arteries and jugular veins. We were also able to spend time with the environmental management manager. He assisted and wired the hospital, which was very unique and shows that rural healthcare also utilizes resources from the surrounding area and benefits other occupations.

The third day we were able to participate in rounds at Pine Hills Nursing Home. These rounds consisted of a nurse practitioner, nurse, case manager and pharmacist. It was cool to see how close providers get to their patients even in a less controlled environment like a nursing home. The rounding staff goes into patient rooms to perform rounds for convenience to the residents.  We were able to see a callous removal done in a patient room. Some of the referrals that were made forced patients to go to regional, but most of them allowed patients to only travel to Fall River Hospital for convenience. We also met with the food service manager and the infection control staff member. Many rural settings are just getting started with infection control, which can be a challenge for finding rural staff members able to take on this task. We then met with the health information management staff for computer training and to discuss computer systems. One obstacle that they have to overcome is the tendency of providers to not utilize new technology in the workplace. We also met with the social worker at the facility and she discussed that western south Dakota does not have enough nursing home beds to cover the population since the state has put a cap on nursing homes. Seven Sisters Nursing Home was allocated 11 more beds and planning for these beds has started.

Thursday we were able to participate in rounds at the State Veterans Home. There are many military relics in the home and it was awesome to see the pride in the armed forces that the community of Hot Springs has. Some of the veterans struggle to get family to come see them because it is a long drive for family to the rural town of Hot Springs. Residents are always participating in events in the community and going out in the town. We also met with the speech pathologist on Thursday. She described how many different cultures present at the hospital and all the other facilities she works and her role. One challenge she enjoys is the Native American population that presents to the hospital. Many of the older Native Americans struggle with English and possibly only speak Lakota. She enjoys being able to help these patients communicate and is unique to the South Dakota rural health setting. She also described the challenges of receiving funding for new equipment because of the budget constraints that the hospital has being a small facility. The last thing that I did Thursday was meet with the head pharmacist about management and she discussed how her position allows her to go directly to the CEO to start new programs in the pharmacy.

The last day of the week I spent only in pharmacy and participated in many of the daily activities. I was able to perform a medication reconciliation upon admission and discharge. The patient upon discharge was being cared for by friends from Rapid City while the couple was in the hospital. I was able to appreciate how well friendships bring together people around the hills, even to the extent of being the primary caregiver of a friend. I also participated in hospital rounds that included PT, OT, speech therapy, nursing, doctor, pharmacy and the case manager. They emphasized getting patients home at the earliest date possible to get patients back to their usual selves. I also was able to practice administration of a subcutaneous medication on a patient. We were able to observe medication administration by PEG tube on a patient. The pharmacist also assisted me on dosing vancomycin. The pharmacy contracts with Avera to have medication reviews when pharmacy staff is not at the hospital, which is very convenient for pharmacists and technicians so that they do not have to come into the pharmacy as much when they are on call. The rural setting forces almost all medical professionals to be on call when they are not at work and frequently have to come in to take care of patients since most departments do not work overnight.

During our off time we were able to visit many local attractions, including Wolly’s Grill and Cellar, Evans Plunge, Jewel Cave, Custer State Park, Hike Black Elk Peak, Sylvan Lake, Kidney Springs and see the mostly sandstone architecture of downtown Hot Springs. The Native Americans recognized the warm water to be medicinal in the area, and Hot Springs still continues the therapy through the many healthcare facilities in the town.

Week 2:

The second week of our REHPS experience was very busy with activity. Monday we started with the daily huddle for the hospital floor and working up patients in the pharmacy for discussion. After rounds, we met with the head of respiratory therapy and she discussed what her department does on a daily basis. One challenge that rural healthcare runs into is intubating of patients. Fall River does not intubate patients unless they are going to be transferred to another facility. This stems from the lack of personnel and resources that the hospital has because of it’s rural setting. Ed from ultrasound was able to have us shadow during an arterial and venous leg ultrasound on a patient. This was particularly interesting because the patient had MRSA precautions and we had to gown up to enter the room. I was then able to shadow a PA and see what clinic visits are like. I really enjoyed this because I have never seen what providers do behind the scenes when a patient presents to the clinic. The last thing I did on Monday was prepare for the Psychotropic Drugs, Moods and Behaviors Assessment (PMA) meeting that we were asked to present at.

The next day we started off with the daily huddle and pharmacy huddle to discuss when patients are being discharged and problems to address during the day. Shelly, our preceptor, had us work up the patients that were being reviewed for the PMA meeting where we mostly discussed gradual dose reductions that are mandatory to be attempted if not clinically contraindicated for psychotropic medications. It was very eye opening to see how much insurance plays a hand in patients care. Even though Fall River Hospital is small, they do not have a problem keeping up with better ways to address requirements, like gradual dose reductions. The hospital is an exception to most rural settings because of the mental health providers that are located on site and able to evaluate patients and the need for these medications. I also was able to round with Brenda, a nurse practitioner, at the State Veterans Home. Because the town is very small, most of the providers work at many other locations besides Fall River. Brenda is one of these providers that services multiple locations. I did not realize that providers serviced multiple facilities in the rural setting. The day ended with Swing bed rounds where the whole healthcare team goes into patient rooms to discuss the care, timeline of stay and answers any questions that the patients have. All of the patients were ready to go home and return to their daily routine and catch up on work and other activities. The patients were very conversational, and many patients knew members of the healthcare team, which does not happen nearly as much in urban areas.

Wednesday I was able to shadow Greg Zike, a PA that works exclusively in the clinic at Fall River. Providers truly have to be ready for anything when in a rural setting. Every case was a new challenge and it was very cool to see the diversity that even the small town of Hot Springs can have. From a pharmacy standpoint, it was easy to figure out which pharmacy to send prescriptions to because there are only two community pharmacies in the town. The pharmacist had a question about one of the prescriptions and was able to reach the PA very quickly to resolve this issue, which probably would not have happened in a large city. The provider also knows the community pharmacists well and has a good working relationship with them. Azra and I then met with Brian, the Medicare coordinator. Although Medicare is universal to all facilities, one problem that he addresses most commonly is travel leaving the facility because many patients live a large distance from the facility. He also leans toward the side of caution when considering patients’ status when sending them home because help is usually a long way away.

Thursday we were able to shadow in the OR under Dr. Lias as he performed two colonoscopies and two esophagogastroduodenoscopies. This was an awesome experience and we were able to see the pre-op and post-op scenarios and how the nurses, anesthesiologist and doctor all work together to make the procedures run smoothly. In the rural setting, scheduling patients is challenging because procedures only occur on Thursday every week. The procedures that occur at Fall River are also limited because of the lack of specialists in rural areas, but the procedures that they are able to perform are very convenient for patients. It also was apparent that doctors must travel in rural settings because Dr. Lias is based out of Chadron, Nebraska. We then met with Brian who is responsible for antimicrobial stewardship at the hospital. This program is mandated by law.

Friday we worked with the pharmacists to prepare for the morning hospital huddle and pharmacy huddle. This day in particular it was apparent that everyone in the hospital wants these patients to be in an environment that is as close to home as possible by moving them into the day room for a change of scenery. After the morning huddle, Azra and I were able to meet with Dr. Parker, the psychologist. I asked him how he decides that a patient needs medication for their condition which led to a two hour discussion on many areas of the treatment process. One of the discussion points that focused around rural health was the amount of travel that patients have to do to come in for appointments. He stated that some patients do not even consider coming in for appointments during the winter or harvest season. He also stated that many mental disorders go undetected in rural settings because of the stigma around rural health as well as the lack of knowledge on all the services psychologists offer.

In our free time, we were able to go to the gym at Evans Plunge as well as eat at local ice cream shops and restaurants. Saturday we were asked to walk in the parade in front of the Seven Sisters Living Community resident van in the Miss South Dakota parade. This was cool because many of the people watching the parade knew us and the other workers who walked in the parade. After the parade, we were able to go see Mount Rushmore, go through Bear Country USA, walk through Keystone, got to Prairie Berry Winery and walked around Rapid City to see art alley and all of the statues of presidents.

During our off time we were able to visit many local attractions, including Wolly’s Grill and Cellar, Evans Plunge, Jewel Cave, Custer State Park, Hike Black Elk Peak, Sylvan Lake, Kidney Springs and see the mostly sandstone architecture of downtown Hot Springs. The Native Americans recognized the warm water to be medicinal in the area, and Hot Springs still continues the therapy through the many healthcare facilities in the town.

Week 3:

Monday was full of pharmacy activities, including drug research, putting away the order and discussing medication changes with providers. The pharmacy students were also asked to do a narcotic audit that compares Omni cell machine records and medication administration records.

On Tuesday, I was able to participate in morning rounds for swing bed patients in the hospital. I was able to suggest a medication change that was accepted by the attending physician. After morning huddle, I was able to shadow Jim Woehl CNP at the State Veterans Home to see patients on rounds. We were able to see a skin lesion cryotherapy treatment, thrush diagnosis, press ulcer diagnosis and a carpal tunnel surgery referral. When speaking with Mr. Woehl, he discussed why he preferred to work rural compared to urban. He discussed that in larger facilities, you do not get to know the patients and treat the patient as a whole instead of bits and pieces with multiple specialists where things can get overlooked. A large problem of older populations in the rural area is depression. Almost all elderly patients are some sort of depressed. In the rural setting, many times people do not talk about depression and think that they just have to “tough it out” because that is the mentality in Rural America. In the rural setting, healthcare team members get to treat all sorts of patients instead of just staying in their specialty. Many people do not realize that you can still specialize or find a niche in the rural setting, even if you do not see the high quantity of specialty-specific patients. Mr. Woehl found his niche in Hepatitis C early in his career and became the expert in the area. We were also able to participate in swing bed rounds where the healthcare team goes into patient rooms to discuss care with patients.

On Wednesday, we were able to attend swing bed rounds with the healthcare team before we went to shadow Andrew Yantes CNP for Pine Hills Assisted Living provider rounds. These rounds include a nurse, provider and pharmacist typically. One of the patients was confused on what a nursing home is compared to assisted living and after explanation she and her husband were able to discuss a possible move to this new setting after months of patient frustration at the facility. It is interesting to see how people do not have time to pay attention to what assisted living centers and nursing homes do because they are busy living normal, healthy lives. Many times healthcare is underutilized because of lack of public knowledge of services, particularly in rural settings where some patients do not have easy access to this information. After rounds, I was consulted on many antibiotic questions for appropriateness in the pharmacy. Medication selection is always limited in accessibility in the pharmacy, but particularly limited in rural settings because it is not beneficial to carry a wide variety of some drugs if patients are transferred out of the facility in the situation that they would get them. Fall River Health Services does have outpatient infusion services that benefit patients by not having to travel nearly as far.

Thursday was a busy day in the pharmacy, so much so that we had to cancel the VA tour in the afternoon that was scheduled. The morning swing bed hospital huddle was very promising and had 3 discharges from the hospital before the weekend. Almost every patient is eager to get out of the hospital and get back to their daily routine in the community. We were also able to sit in on an infectious disease teleconference for a patient with Dr. Strom from Rapid City. Telemedicine is the direction rural healthcare is going to get people to see specialists in their hometown. I also performed a newly implemented weekly narcotic audit along with many other daily pharmacy activities.

Friday after rounds, I was able to perform a medication reconciliation for a patient transitioning to the hospital from another facility that also receives medical help at home. This was one of the more challenging tasks that I have performed in this experience because of the complexity of the case and the numerous medication lists that I needed to work with. I was able to shadow physical therapy in the hospital as well as the outpatient clinic to help perform exercises as well as use a tens machine and set up an ambulatory tens unit. These therapies are an awesome alternative and/or addition to medications to help with pain and physical therapy. We ended the day working on our billboard where I displayed non-pharmacological ways to help with sleep.

On the weekend, we were able to go to The Vault for dinner on Friday. Saturday, we accompanied Shelly and her family to spend a day on the boat at Angostura Reservoir and sitting around the campfire. Sunday Azra and I were able to go to the Hot Springs Arts and Crafts Festival, drive through Custer, Hill City, Needles Highway, walk around in Deadwood and drove through Spearfish Canyon. It is amazing that I have not seen some of the places that we have been on this experience and I live in the area.

Week 4:

My last week in Hot Springs was jam-packed with great experiences that I will remember for the rest of my life. Every morning we were able to participate in the interdisciplinary swing bed huddle to discuss patients in the hospital and make recommendations for medication changes. Monday, we were involved in a full code situation with a patient who required Lukas machine compressions and pharmacological treatment before being air lifted to Rapid City Regional Hospital for further treatment. This opened my eyes to the role rural hospitals play in saving lives and strict organization and composure in these situations to get patients stable and ready to transfer to a larger facility. All healthcare professions in the hospital, including providers, nurses, pharmacists, respiratory therapy, radiology and social work all came to the ER to help in the code. Every member of the healthcare team that would be involved in emergency situations needs to be prepared to handle these types of situations. In the rural setting, you cannot shy away from these situations and must be ready to handle whatever comes through your facility.

Azra and I also were able to shadow in the Fall River Veterinary Clinic. Many of the same problems that human healthcare facilities encounter are also present when taking care of animals, including maintaining staff and medication shortages. The clinic rescues approximately 1000 dogs and cats from the reservation, which was cool to see how much of an impact one clinic can make. We were also able to see an ultrasound of a horse to see if a pregnancy took and basic clinic services as well.

Tuesday we were able to participate in the weekly interdisciplinary swing bed meetings with patients and discussed plans after discharge for patients. Megan, the other pharmacy student, and I were able to get a tour of the ambulance service facilities. They have three ambulances and a helicopter at the facility at all times ready to transport patients. It was interesting hearing the process of accepting patients for transport because they must be unbiased to the risk associated with taking on jobs. It was also intriguing to see the inside of the helicopter and all of the equipment that must be on the aircraft to maintain patients through transport. The helicopter transport out of Hot Springs is used by Pine Ridge and other small hospitals around the area as well. These services are vital to get patients to the treatment they need in rural places that do not provide the specialized care that they require.

Azra, Megan and I were able to see a medication pass as well as observe a PEG tube medication administration on Wednesday. Fall River Health Services holds many events to keep their employees trained and ready for any situation that could devastate the community. We were able to attend an All Staff Meeting where they discussed safely lifting patients as well as disaster preparedness. This meeting really emphasized that the hospital plays a vital role in caring for the community in a disaster situation and using all resources, which are limited in a rural setting, in the hospital to address disasters smoothly. We were also able to attend a Quality Assurance meeting where some of the hospitals important stakeholders were present to address the care and progression of programs in the hospital.

After the daily hospital huddle, we were able to travel to Pine Ridge to see the hospital and the reservation. This was an eye-opening experience. I was very surprised at the amount of poverty that is present just a short drive from Hot Springs. After touring the pharmacy, ER, mental health and OB, we went to the new Oglala Sioux Lakota Nursing home in White Clay, Nebraska. The nursing home takes only Native Americans on Medicare. The facility was beautiful and only half full, so there is still room to bring more Native Americans home to live.

Friday we were able tour the federal VA Campus and see the historic facilities on the top of the hill. The pharmacists are very involved with patient care because the government only lets patients see their doctors yearly. They have set up pharmacy anticoagulation and pain clinics and are working on new ways to help patients manage their disease states. We were also able to see a telehealth clinic room for specialists to see their patients. This is an amazing tool that rural hospitals can use to get the care that patients need, even if it is not face to face. We finished the day by giving our Opioid Epidemic Presentation and a few other pharmacy activities.