A court run by teens helps keep their peers out of trouble in Robeson County.

By Hyun Namkoong

North Carolina is one of only two states in the country that try 16- and 17-year-olds as adults in its criminal justice system. This means that a lunchroom scuffle can leave an indelible mark on a high school kid’s record.

The North Carolina Academic Center for Excellence in Youth Violence Prevention wants to keep young people out of jail. It’s an organization that implements programs to address violence in Robeson County – one of the poorest counties in the state – through a collaboration that involves community, school and health organizations as well as the UNC School of Social Work and nearly $6.5 million from the Center for Disease Control and Prevention’s National Center for Injury Prevention and Control.

Judge J. Stanley Carmical speaks to juror Derrica Lorick, 14, while juror Danny Carver, 13, and clerk Hannah De La Cruz, 13, look on. Photo credit: Hyun Namkoong

NC-ACE uses its Teen Court to divert first-time nonviolent offenders from district and juvenile court.

“A kid who fights? Assault. That’s it. A criminal record for life,” said Jim Barbee, center coordinator, of what can happen when a young person enters the adult criminal-justice system.

Teen Court, he said, “is a great opportunity to give them a second chance.”

Positive peer-pressure in the courtroom

The small, crowded courtroom in the Robeson County Board of Elections building looks a lot like any courtroom you might see on TV, with the notable exception of the dozen teenagers who act as jury, defense attorney, prosecution and clerk.

A 15-year-old girl swears in the proceedings of the court and Judge Stanley Carmical allows the defense attorney and the prosecution to make opening remarks.

A jury of nine teenagers listens to the case of a teen who has been charged with disorderly conduct in his English class.

During questioning, the defendant admits that he causes disruptions, but only in English class because of the frustration he feels from lagging behind in reading.

Teen Court targets offenders aged 11 to 17 years old who have been charged with a nonviolent offense, such as simple possession of marijuana, disorderly conduct or underage consumption of alcohol.

The objective is to lower recidivism – the likelihood of reoffending criminal behavior that lands teens right back into trouble – through positive-action peer modeling. Offenders are paired with a peer who acts as their defense attorney during their trial. Research shows that during the turbulent years of adolescence, peers have the most influence on social behavior.

Following the closing remarks from the defense attorney and prosecution, Judge Carmical allows the jury to deliberate the details of the trial and decide on the sanctions for the defendant, which are akin to a sentence.

The members of the jury have all been in the shoes of the defendant. First-time offenders are all required to serve at least one session of jury duty as a part of their sanctions. Social-control theory suggests that teens respond better to sanctions from their peers rather than adults.

As facilitators for the jury deliberations, Alejandra Reyes and Colin Benton, students at UNC-Pembroke, follow the jury to a roundtable discussion.

“I see a lot of improvements,” Benton said of the teenagers who serve on the jury. “Biggest thing I like is, I get to see them grow as a person.”

Attorney advocate Samuel Deese, 18, speaks to jurors (l to r) Derrica Lorick,14, and Sandy Miller,13. Photo credit: Hyun Namkoong

Behind closed doors, the jurors discuss the frustrations of falling behind in class and problems with teachers. One juror thinks the defendant might have a self-esteem problem as a result of his difficulty with reading. Another teen talks about his own experience of acting out when he didn’t understand the class material.

Teen Court uses a restorative-justice model, which goes beyond punishment. It emphasizes offender accountability, restoring community trust in the offender and reparation.

After much deliberation, the jury members agree upon a sanction of 18 hours of community service and five sessions of duty on Teen Court. The defendant must also write a letter of apology to his classmates for disrupting the class. The jury also instructs the defendant to attend self-esteem, anger-management and good-decision seminars. It further recommends a parent-teacher conference and English tutoring for the defendant.

“We don’t try guilt or innocence. We focus on kids having accountability,” Barbee said.

Violence prevention is health related

At first glance, Teen Court doesn’t appear to be a health-related intervention. But Brad Bartholow, a research psychologist with the CDC, argues otherwise.

“The CDC considers violence a public-health issue,” he said. “Plenty of health departments don’t think that. They think about flu, immunizations.”

The CDC and other health organizations have started to more closely examine “social determinants” of health. These are the social, economic, environmental and political forces that shape and impact people’s health. Social determinants of health are commonly referred to when discussing health disparities between different populations.

Robeson County is one of the few rural counties in the nation that has a majority-minority population – that is, the total of the black, Latino and Lumbee Indian populations comprises a majority.

Nationwide, black communities are disproportionately affected by incarceration. Black adolescents represent more than half of the youth who are admitted to state prisons.

A study from Princeton University investigating the impact of a criminal record on job seekers found that it reduces the likelihood of getting an interview by 50 percent for white males. The findings paint an even more dire picture of black males with a criminal record: They’re significantly less likely than white males with a criminal record to secure stable employment after incarceration, rendering major economic and social ramifications for their communities.

“Health consequences from violence are a tremendous cost to society, financially,” Bartholow said.

Hope for a brighter future

The focus of social determinants on health also underscores the role that place and environment play in affecting health outcomes.

Gun violence, drug trafficking and high rates of crime are commonly associated with inner cities, which is why the rolling acres of farmland, the winding Lumber river and the swamps of Robeson County make it seem an unlikely place for the state’s highest homicide and juvenile-arrest rates.

Teen Court juror Cierra Dial, 17, says she learned to avoid trouble through participating in the Teen Court process. Photo credit: Hyun Namkoong

I-95 roars through the idyllic scenery of Robeson County; it’s approximately halfway between Miami and New York City. Eager to attract businesses to the area, local officials promote the county’s “Interstate logistics,” but illegitimate businesses, including drug trafficking by national and international cartels, have also capitalized on the county’s strategic location.

Throughout the years, there have been multiple drug busts, sting operations and even high-profile cases of corruption involving the sheriff’s department.

Robeson County offers few opportunities for its young people. The inescapable violence, poverty and crime have the potential to create a sense of fatalism for young people and the direction their lives can take.

But preliminary evaluation of the Teen Court program indicates that it’s successful in increasing optimism and hope for the futures of its teen participants.

Cierra Dial, a 17-year-old who was charged with larceny and now serves as a Teen Court jury member, said that she is looking to the future and would like to pursue a career in nursing or dental care.

“I’m not shoplifting again,” Dial said.

“I put effort in it and try my best,” she said.

As lawmakers argue over the future path of Medicaid, they point to uncertainty over the amount of money spent by hospitals participating in the program.

By Rose Hoban

When talking about how convoluted hospital finances can be, Mark Holmes has an analogy: “In a construction business, you pour 40 yards of concrete and bill the client for 800 bucks,” said the health economist, who teaches at UNC-Chapel Hill.

“But if construction companies got paid the way hospitals do, they’d pour the concrete and send a bill for $1,000. Then four weeks later, they’d find out what they get paid for it, and it’s only $800 – or less.”

According to Holmes, that metaphor gives a slight glimpse into the strange and complicated world of hospital finances and billing.

N.C. Hospital Association lobbyist Cody Hand talks with Sen. Ralph Hise (R-Spruce Pine), co-chair of the Senate Health and Human Services Committee. Photo credit: Jasmin Singh

Last month, as lawmakers in the House and Senate began sparring over the state budget, one of the most vexing questions they faced was how to calculate what hospitals spent on caring for Medicaid patients last year and how much they were still owed for that care.

Lawmakers were having trouble reconciling this year’s Medicaid numbers because of difficulty getting data out of the NCTracks Medicaid billing and claims processing system, which launched a year ago and has struggled since.

Sure enough, when budget time came, there was no way to create a projection for the coming year or reconcile the unpaid bills from last year.

So lawmakers turned to hospitals themselves, asking hospital finance officers what they thought they were owed. And the answer they got back was a collective, “We’re not sure.”

That’s because hospital accounting is different from keeping the books for other kinds of businesses – very, very different. And very difficult.

And the difficulty in calculating hospital costs has only added to the uncertainty at the General Assembly over how much lawmakers should set aside to resolve Medicaid’s debts.

Complicated, confusing

According to Holmes, the rules governing hospital accounting resemble nothing so much as a Rube Goldberg array of guidelines that are created primarily by governmental payers, in particular Medicare, the federally funded program that covers seniors’ health care, and Medicaid, which covers low-income children, some people with disabilities and many elderly who live in nursing homes.

“[Federal authorities] keep adding on different elements, and hospitals need to account for all those differently,” Holmes said.

Southeastern Regional Medical Center’s main campus in Lumberton. Image courtesy SRH

Then there are people who have private insurance – every one of those companies negotiates a different pay rate with hospitals – and then people who have high deductible plans, who often pay the first $5,000 or $7,000 of their medical bills before their insurance kicks in.

“One CFO told me that 10 years ago, he had 15 payers; now he has 20,000 payers,” recounted George Pink, another health economist from UNC-Chapel Hill. Pink’s area of expertise is in health care finance.

Hospitals now have many patients with those high-deductible health plans “and you have to collect money from them. In a sense, they’re their own insurers and they’re more likely to default on their debt,” he explained.

Thomas Johnson is one of those chief financial officers. He manages finances at Southeastern Regional Medical Center in Lumberton, where he has an entire department full of billing employees that deal with all the intricacies of getting a claim out the door.

“If it wasn’t so complicated, we could take a lot of cost out of our systems,” Johnson said. “So much of the overhead in health care today is directly related to the complexity of having to track and monitor what it takes to be able to bill a claim and get it paid.”

He said some studies show that the insurance and billing processes alone add between 20 and 25 percent of the cost of care in order for hospitals to make ends meet.

No pay, some pay, almost never full pay

Johnson explained that his hospital is the safety net hospital for Robeson County, where Southeastern Regional is located, as well as for several surrounding counties.

About two-thirds of Southeastern Regional’s patients are on either Medicare or Medicaid; an additional 10 percent are uninsured.

“We have to take all comers. All hospitals do,” Johnson said. “In our situation, we have more of the uninsured and the Medicaid population because of our geographical location. It’s a very poor region.”

And the hospital’s operating margins show it: Southeastern Regional’s run, at best, between 2 and 3 percent per year.

“We’re cutting costs left and right; there are layoffs across the state and hospitals are eliminating money-losing services,” Johnson said. “Nonetheless, we’re seeing a lot of downsizing of hospital payrolls and expenses.”

Across the state’s 135 hospitals, the average operating margin is 1.8 percent, according to the North Carolina Hospital Association. That’s down from an average of 2.8 percent in the previous fiscal year, said Julie Henry, spokeswoman for the NCHA.

“Often, hospitals are taking care of people they know they’re not going to get paid by,” she said.

“It’s not like other businesses, where you pay when you get the service,” said Hugh Tilson, vice-president for governmental affairs at the NCHA.

“We provide the service first and then figure out how to pay for it,” he said. “Then, most times, someone else is paying; two-thirds of the time it’s the government, 25 percent of the time it’s someone with insurance, and the rates from all the different insurers all differ.”

Tilson explained that often a patient will walk in and get treatment for an acute condition and a financial counselor meets with them, and the patient says, “I’m eligible for Medicaid.” The hospital then applies for Medicaid for them and they might not know for months if the person is covered.

In the hospital’s accounts receivable budget, the amount that person owes might appear as the amount Medicaid would pay. But if the patient isn’t covered by Medicaid, it becomes self-pay and the hospital has to go back to that person and negotiate a payment schedule.

Not to mention the past two years of rate cuts to Medicaid that have eaten away at reimbursement.

“It’s hard from the hospital perspective to track revenues from a particular service to a particular patient in a timely fashion,” Tilson said.

These kinds of uncertainties over payment are part of the reason why hospitals couldn’t tell lawmakers “this is what the state owes us” during the early part of the budget process – because they had no way of knowing.

NC Off-Tracks

But the other big budgeting problem for hospitals – and for lawmakers – came out of problems with NCTracks.

The system was supposed to give providers and hospitals the “real time” ability to track the claims that they’ve submitted to the state Medicaid program.

But it hasn’t turned out that way.

“If NCTracks was fully functional, then not only would hospitals have a more clear picture of what their claims status is with the state, the state would not have to ask us how much they owe our hospitals,” said the NCHA’s Julie Henry.

This year at Southeastern Regional, Johnson said, there have been extra problems, because if the claim submitted to NCTracks is not “clean” – meaning there are no mistakes, no information is left off and there are no ambiguities – then the claim can end up launched into months of delayed payment.

And that’s hurt hospitals like Southeastern Regional, where so many patients are covered by Medicaid, while the payment system has continued to struggle.

“Instead of it getting simpler, it gets more complicated every year,” Johnson said.

The ECU School of Dental Medicine is expanding its statewide network of clinics that offer sliding-scale services and unique educational opportunities.

By Taylor Sisk

Kasey Oxendine always knew she wanted to come back and serve her community. It’s just happening a little sooner than she’d planned.

Rural Rx: NC Health News coverage of rural health issues. This week: Robeson, Bertie, Brunswick, Davidson, Harnett, Hertford, Jackson, Mitchell, Pasquotank, Pitt and Robeson counties.

Oxendine, a third-year student in East Carolina University’s School of Dental Medicine, was back in her hometown of Lumberton last Tuesday for a ribbon-cutting ceremony at ECU’s Community Service Learning Center-Robeson County.

The center is a 7,700-square-foot state-of-the-art facility that will offer dental services to anyone in the county while providing an opportunity for students to gain experience in an underserved community.

Oxendine will be among those students next year.

“Being from Lumberton, I know what a rural area is all about,” she said, “and I know the dental needs in rural areas.”

The university is already administering four CSLCs – in Ahoskie, Elizabeth City, Lillington and Sylva – with two more, in Davidson County and Spruce Pine, opening this winter, and an eighth, in Brunswick County, targeted to open around this time next year.

Since the first one, in Ahoskie, opened about two and a half years ago, patients from 71 counties have been seen at the four centers.

Upon graduation from dental school, Lumberton native Kasey Oxendine plans to return to serve her community. Photo credit: Taylor Sisk

The CSLC initiative aligns with the dental school’s mission to “provide educational opportunities for academically qualified individuals from historically underrepresented groups, disadvantaged backgrounds and underserved areas,” and to “provide and enhance oral health services for underserved North Carolinians.”

In their fourth, and final, year of dental school, students do eight- or nine-month rotations at three of the CSLCs.

The CSLC in Lumberton will open its doors in January and the first round of students will then arrive to live and work in the community. Housing is provided by the N.C. Area Health Education Centers Program, or AHEC as it’s most commonly known.

The center includes treatment rooms, conference rooms and educational space. Initially, there will be one full-time and one part time dentist, and four or five students who also will see patients, as will faculty members. There will be two hygienists and five dental assistants.

Services will be offered on a sliding scale, starting at free. The center will also accept Medicaid.

A particular need

According to a report  published in the N.C. Medical Journal by University of North Carolina-Chapel Hill researchers, in 2010 there were 4.4 dentists per 10,000 people in the state, compared with a national average of six. The researchers found that North Carolina has for the past decade consistently ranked 47th in the nation in dentists per capita.

Greg Chadwick, dean of ECU’s School of Dental Medicine, said that of some 4,500 dentists in the state, about 1,500 are over the age of 54.

Map courtesy NC Medical Journal.

The state’s rural areas are in particular need of dental services. Chadwick said that Hertford and Bertie counties – with populations of more than 20,000 – have one dentist each.

“We realized that we really needed to do something to get more dentists into the rural and underserved counties, and that’s 85 counties out of 100,” he said.

Thus the CSLC initiative. Complementing the effort are loan repayment incentives offered by the N.C. Office of Rural Health & Community Care to dental school graduates who choose to practice in underserved communities.

Wired back to Greenville

Teledentistry will play a key role in the new CSLC’s efforts to improve dental heath in this underserved community.

Conference rooms are equipped with video equipment, and portable gear that takes images of the inside of the mouth will be available. The center will have a feed back to the dental school for consultations and observation.

The ECU School of Dental Medicine will open the doors on its fifth state-of-the-art community service learning center, in Lumberton, in January, with three more scheduled within the next year or so.
Photo credit: Taylor Sisk

And recognizing that many of their patients rarely, if ever, see a primary care physician, staff will be vigilant for indications of high blood pressure, diabetes and other conditions to which underserved communities are particularly susceptible, and make referrals accordingly.

Rep. Charles Graham (D-Lumberton) said the center will be a “great asset to our county,” and that he’s confident the legislature will continue to recognize the value of the CSLC program.

“As we look at the health care needs of our counties statewide,” Graham said, “I think moving forward this will continue to receive the funding it will need. It certainly will be something we’ll keep our attention on.”

Measuring success

Chadwick said the dental school recently hired an associate dean for research and is beginning to gather baseline data on the CSLCs. He said the school also has a statewide database of electronic health records that allows practitioners at one CSLC to compare the incidence of particular conditions and outcomes with those at another.

Greg Chadwick, dean of ECU’s School of Dental Medicine, at a ribbon-cutting ceremony for the school’s new community service learning center in Lumberton. The center in Lumberton will offer a full range of onsite and teledentistry services. Photo credit: Taylor Sisk

“I think this is an incredible model,” said Robin Cummings, the state Department of Health and Human Services’ deputy secretary for health services and head of the state Medicaid program. “I think it’s a visionary model. I think it’s in keeping with what East Carolina [University] has set out as their goal, and that’s to bring health care to rural North Carolina.”

“Health care’s got to change,” Cummings said. “It’s getting more and more expensive, it’s getting more complicated, and the model that we’ve used in the past is not going to be a model that will work in the future.

“So visionary ideas like this – the use of technology, which they use quite a bit of – that’s what we’ve got to do in health care to try to control costs and take care of more people.”

Bill Smith, Robeson County’s public health director, appreciates the sliding fee scale.

“People who don’t have the ability to pay for dental upfront – which a lot of people have to do – can now be seen,” he said. “And at the same time, it’s teaching dentists and expecting those people to remain in this region.”

Which is exactly what Kasey Oxendine intends to do.

“Some people want to get away and stay away,” she said. “I enjoy the experience of being away, but it’s always been my desire to come back.”

And that’s music to Greg Chadwick’s ears.

Health care in North Carolina was often the big story in 2013, with the debate over Medicaid at the top of the list. But some of our most popular stories of 2014 were small stories that our reporters discovered and readers found interesting, intriguing and significant.

This is North Carolina Health News’ list of the Top 10 (actually, 11) health stories of 2014, based on the web traffic these stories received over the year.

Disagree with our list? Think we missed something? Let us know!!

1. North Carolina’s Medicaid program will change, we just don’t know what it will look like yet

Members of the Medicaid Reform Advisory Group listen to speakers during a meeting in February. L to R: Sen. Louis Pate, Richard Gilbert, Dennis Barry (chair), Peggy Terhune and Rep. Nelson Dollar. Photo credit: Rose Hoban

Medicaid was one of the most varied and “interesting” stories of the year. First came the Medicaid Reform Advisory Group, which recommended changing North Carolina’s Medicaid program to a system that incentivized providers to create accountable care organizations to deliver services to the state’s almost 1.8 million Medicaid recipients.

But members of the state Senate didn’t like the plan, and the future of Medicaid become one of the most contentious issues dividing the House and the Senate throughout the “short” legislative session. Finally, the legislature adjourned without resolving the Medicaid question and convened another committee process this past fall to examine options for the program’s future. That process recently ended with yet another contentious debate over the shape of the program and a vote that revealed a rift between House and Senate members.

All the while, activists, academics and members of the legislative Democratic caucus maintain that expanding Medicaid, as provided for under the Affordable Care Act, is the right move. They’re finding some succor in statements made recently by Gov. Pat McCrory and Department of Health and Human Services Sec. Aldona Wos.

Medicaid will likely continue to be a divisive issue during the upcoming “long” legislative session that begins Jan. 14.

Pam Scheffer-Bossardet (back to camera) helped organize the Vietnam Veterans of America Morrisville meeting and moderated questions from the audience of about 150 people over the course of three hours. Photo credit: Rose Hoban

2. Vietnam Vets still looking for answers on Agent Orange

Vietnam veterans are still seeking answers from the Department of Veterans Affairs over the long-term effects of the defoliant Agent Orange. The VA admits that dioxins in Agent Orange cause a plethora of health effects, and former soldiers exposed to the chemical have higher rates of some cancers, leukemias, lymphoma, Parkinson’s disease and diabetes. Now evidence points to the presence of genetic diseases in the children of these exposed soldiers, but there are still many questions.

The Vietnam Veterans of America has been sponsoring public meetings around the country, including the first North Carolina meeting, held in Mooresville in February. Subsequent meetings have taken place in Wilmington and Asheville.

3. NC elementary students get paddled, mostly in one county

Only a few school districts in North Carolina continue to allow corporal punishment for students who act out. One district, in Robeson County, accounts for the vast majority of the state’s incidences of paddling, a story that got a lot of attention from readers.

4. What’s in this year’s Health and Human Services Budget?

For the third year running, we compiled tables on the North Carolina budget comparing what the House wanted, what the Senate wanted and what was finally passed by the entire legislature. It’s a feature that readers appreciate: We know that from the numbers of page views and the amount of time readers spend poring over the details.

Our interactive map showed readers what they could expect to spend on the health insurance exchanges.

5. North Carolina *hearts* Obamacare

After a rocky start, the health insurance exchanges created under the Affordable Care Act (Obamacare) finally got rolling in North Carolina in a big way, and surpassed the expectations of many.

Readers also spent a lot of time on our interactive map of Obamacare premium rates.

6. Carcinogens lace municipal water near coal plants, coal ash ponds

One afternoon, our environmental health reporter, Gabe Rivin, was digging around on the website of the Environmental Protection Agency when he noticed consistently high levels of trihalomethanes, a family of carcinogenic chemicals, in water near coal ash ponds. After digging deeper, Gabe found that trihalomethanes have been fouling municipal water systems near the ash ponds for years. There’s little regulation of the precursor chemicals that create trihalomethanes in municipal water treatment systems. Gabe also found that hydraulic fracturing (fracking) could create the conditions for formation of these same carcinogens in municipal water systems downstream of fracking sites.

Leslie Sharpe stands in the laboratory space of the Sylvan Health Center, where blood samples and supplies are stored. Photo credit: Hyun Namkoong

7. Nurse practitioners step in to provide rural health care

As the debate over the future of Medicaid plays out in Raleigh, conditions on the ground are shifting and moving ahead. In Alamance County, much of the care for rural patients – both those with Medicaid and people who lack any health insurance – is being provided by a nurse practitioner who runs a clinic out of a trailer on the grounds of an elementary school.

Look for more reporting on rural health issues in the coming year, courtesy of a grant we received from the Winston-Salem Foundation.

8. BPA can play a role in breast cancer cell formation

Scientists at Duke University and at the National Institute of Environmental Health Sciences, based in North Carolina, have been active in research around bisphenol A, otherwise known as BPA, a chemical used to make plastics and epoxy resins.

In June, Duke researchers shared new evidence that BPA not only accelerates cell growth in inflammatory breast cancer but also makes disease treatment less effective.

Skyler Thompson hands Marlo Duncan a baked potato at the NC State Fair in October. Photo credit: Rose Hoban

9. Looking beyond deep-fried at the NC State Fair

Once again, editor Rose Hoban went looking for healthy food offerings at the annual state fair, and actually managed to find some delicious and fun offerings that won’t make your cardiologist hang his or her head and weep.

10. Ebola-tracking software created in North Carolina

As the world watched in horror as the Ebola virus ravaged populations in West Africa, students from UNC created software to track the virus’ spread through Liberia.

The website is used by government officials in that country to track the disease on a daily basis.

Karyn Traphagen, Tully James and his mom, Karen, celebrate Tully’s new hand. Photo credit: Jasmin Singh

BONUS: DIY prosthetic hands printed locally help kids with disabilities

Geeks are getting more love these days for being creative, inventive and prolific makers of cool stuff. Now 3D printing technology is allowing local inventors to construct prosthetic devices for people with physical disabilities.

This story was written, photographed and filmed by our wonderful summer intern, Jasmin Singh, who kept bugging her editors to try more “alternative” story forms.

This was our attempt to look a little more like Buzzfeed. See what you think.

Hospital executives returned to the General Assembly Tuesday to walk the halls and promote their plan for reforming Medicaid.

By Rose Hoban

After years of cuts to their Medicaid reimbursements, increased assessments by the state government and shrinking clout at the General Assembly, executives from the state’s hospitals came to Raleigh Tuesday to promote their plan for Medicaid and talk to legislators.

Close to 300 CEOs, nursing directors, nurses, doctors and other hospital employees roamed the halls on Jones Street, heading into legislators’ offices and showing off some of their newest pieces of technology.

But primarily, they were there to make the case that their institutions are doing a lot to improve health care across the state.

“We need to be innovative, we need to look at different ways of doing things,” said Michael Lutes, CEO of the Carolinas HealthCare System hospital in Anson County.

Lutes and others were hoping to convince lawmakers that they were ready to be partners with the state to reform the system and get back on an even financial keel.

WakeMed nurse David Crosby showed off some of the new technology being used at the hospital to provide care and keep nurses up to date. Photo credit Rose Hoban

Cody Hand, lobbyist for the North Carolina Hospital Association, said one of the tasks for the day was to thank House lawmakers for not putting more cuts to hospitals into their Medicaid budget.

“The House budget recognizes that Medicaid needs to transform, and providers can’t do that with continued cuts,” Hand said. “It’s a fairly responsible and rational budget.”

Transformations

Transformation was a big theme of the day, with one of the courtyards in the General Assembly building filled with tables and exhibits of new ways of meeting patient needs.

Nurse David Crosby from WakeMed Health & Hospitals showed off a teaching mannequin and a portable respirator at a table right outside the office of Senate Health Care Committee Co-chair Louis Pate (R-Mt. Olive).

Crosby also talked about WakeMed’s agreement with Wake Tech Community College to get young associate degree nurses to the bedside.

“Students do an early college while they’re in high school, so junior and senior year typically most of their classes, if not all of them, count towards college credit,” Crosby said. “And with the nursing program, they can start clinicals once they’re 18.”

The transformations also extend to how hospitals are built and how they deliver care.

“Our model that we’d been delivering for a number of years just wasn’t working,” Lutes said. “So what we wanted to do before we built a new facility was really redesign the care model.”

He described how his institution reconfigured itself from a traditional full-service hospital to a facility with only a few beds, plus ambulatory care clinics and an emergency department for more acute patients.

He said the new facility was about to celebrate its first anniversary and he was looking forward to presenting data showing they’d reduced overuse by some chronically ill patients.

“We had one particular patient who had visited the emergency about 14 times during the last year at our old facility,” said Lutes. The woman had several chronic diseases.

“When the new facility opened, she visited us about three weeks into the facility,” he said. “We got her into our patient-centered medical home to do the follow-up care she needed. Now, over the last nine months, she’s only come to the emergency department one other time.”

Medicaid plan

The biggest transformation hospital executives wanted to talk about was their recent proposal to reform Medicaid by creating “provider-led entities” made up of doctor groups, hospitals and other health care providers. These PLEs would eventually get paid a set fee from the state for each Medicaid patient, and in return they would guarantee a predetermined level of quality and satisfaction for patients.

The hospitals’ plan would also exclude out-of-state managed care companies from being part of the mix.

“Lawmakers can have the budget certainty they need and we can have a little more control over the risk that we are already providing and already assuming,” Hand said of the plan.

“I think the health care systems around the state are willing to step up and have a local North Carolina solution to Medicaid reform,” said Lutes, pointing to his organization’s early success in Anson County.

Certificate of need

Other CEOs said they were talking to lawmakers about preserving the state’s certificate of need laws, a sprawling and complicated regulatory regimen that limits the amount of health services available in the state as a way of controlling costs and reducing overuse in health care.

Southeastern Health CEO Joann Anderson said she worries that changes to certificate of need laws would undermine her hospital’s financial stability. Photo credit: Rose Hoban

Several proposed bills would significantly change certificate of need laws: one would eliminate it altogether and another would allow for the construction of freestanding ambulatory surgical centers that would be unaffiliated with hospitals.

CEOs such as Joann Anderson, head of Southeastern Health in Robeson County, expressed fear that allowing the ambulatory surgical centers would undermine her hospital’s income. In 2013, Southeastern had revenues of about $270 million. But after paying all its expenses, it had only about $5 million left over.

“That’s what we have to reinvest in the organization, to be able to give our pay raises for our employees, afford benefits for employees, to be sustainable,” Anderson said.

She fretted that independent orthopedic or ophthalmic surgery centers would pull away some of their best-paying patients and said that losing the revenues from those well-reimbursed services would make it harder for her institution to support loss leaders such as maternity services and the emergency department.

“We have a huge network of physicians, and our physician practices lose significantly every year,” Anderson said. “They contribute to the overall organization. But if you just look at that entity of its own, it’s a loss leader for us.”

“But it’s an issue of access to care, so we feel we need to do that.”

Anderson said about three-quarters of the patients at Southeastern Health are either Medicaid or Medicare recipients, which have low rates of reimbursement, and another 10 percent are uninsured altogether.

“So if Medicaid takes a huge hit and the certificate of need goes away, that would strip us, basically, completely, and leave us deciding what services not to provide,” she argued.

North Carolinians are fanning out across the state to spread the word about Affordable Care Act eligibility.

By Taylor Sisk

Catherine Gaines’ sights were set on Beauty Spot Methodist Church, in the Robeson County community of Purvis. Her GPS landed her in a cow pasture.

So it goes: another day in the field for Gaines, a cancer patient navigator with Southeastern Health and now a member of the Affordable Healthcare Coalition of Robeson County. Two steps forward, one step back – through the hollows and down a few dead ends, in search of the uninsured.

Catherine Gaines of the Affordable Healthcare Coalition of Robeson County says, “We have to partner to survive.” Photo credit: Taylor Sisk

Gaines and her AHCRC colleagues are part of a statewide team of individuals, many of them volunteers, dedicated to spreading the word about the Affordable Care Act. Their objective is to educate and otherwise offer guidance to those who might be eligible and to suggest alternatives to those who aren’t.

It’s an all-hands-on-deck effort.

How’re we doing?

First, some numbers:

In 2013, before the first ACA open enrollment period, North Carolina’s uninsured rate was 18.2 percent, almost 2 percent higher than the national average. By 2015, the state’s rate had dropped to 14.6 percent, but was still 3.9 percent higher than the national average.

Rural Rx: NC Health News coverage of rural health issues. This week: Robeson County

But North Carolina has beaten expectations for ACA enrollment. As of the end of June, only four states – Vermont, Maine, Florida and California – and the District of Columbia had enrolled a higher percentage of those eligible for ACA coverage. Forty-six percent of just over a million potential enrollees were signed up.

And the state has the third-highest percentage (91.6), after Mississippi and Wyoming, of residents enrolled who are receiving financial assistance in the ACA marketplace.

The 2016 open enrollment period began on Nov. 1 and runs until Jan. 31, and ACA assisters are deploying from Ranger to Rodanthe (i.e., mountains to sea). As expected, rural areas have lagged behind the more urban ones in enrollment, due in some degree to the fact that because rural areas are less densely populated, and there’s more terrain to cover, it’s harder to reach folks to assist them.

The rural perspective

According to an October Wake Forest University School of Law study, almost 40 percent of the North Carolinians eligible to enroll but who haven’t yet done so live in the state’s 80 rural or largely rural counties.

Median income in those counties is $39,679; it’s $52,382 in the state’s urban counties.

Health care-wise, rural residents face, as a whole, more challenges than those in urban areas. They have access to fewer services and what’s available is more dispersed. They’re more likely to be self-employed, seasonally employed or work for a business that doesn’t provide health insurance.

According to the federal Health Resources and Services Administration, rural families pay almost 40 percent of their health care costs out of pocket.

A full-out assault

The need is critical in rural communities, and ACA navigators are responding with enthusiastic creativity.

Vanessa Abernathy, an Enroll America fellow, is helping spearhead an all-out effort. Photo credit: Taylor Sisk

Robeson County, just to the southwest of Fayetteville, is an ACA success story.

Robeson is approximately 40 percent Native American, 30 percent white and 25 percent black, and now has an expanding Latino population. A third of the county’s residents are uninsured, the highest rate in the state.

Enrollment efforts in the county have entailed what Sorien Schmidt, state director for Enroll America, calls “a great convergence in focus and energy and commitment.” It includes health care providers, federally qualified health centers and other nonprofits, faith communities, business owners, barbers – it’s a community-wide campaign.

“In the business world, they call it total market coverage,” said Vanessa Abernathy, an Enroll America fellow. “You’ve got all these different groups and entities that are moving toward the same goal, which is enrollment.”

A ‘shining example’

In September, the federal Centers for Medicare and Medicaid Services awarded the North Carolina Navigator Consortium $2.6 million to help get North Carolinians enrolled in the ACA during this year’s open enrollment period.

Legal Aid of North Carolina is one of 14 members of the consortium and has been an active presence here in Robeson County. They’ve been joined at the forefront by churches – trusted sources of information in the community.

“If you know anything about Robeson County, you know there are many churches,” said Francine Chavis, a Legal Aid of NC paralegal, born and raised in the Robeson town of Pembroke, and now a certified navigator.

Francine Chavis is working in the community in which she grew up to get people educated about the ACA. Photo credit: Taylor Sisk

Pastors will talk about the ACA from the pulpit or over Sunday supper in the home of a congregation member. And the coalition has held a number or enrollment events in churches.

“A lot of times, you may have half a dozen to a dozen people, 20 people at the max, there to listen to you,” Abernathy said, “and most of them are Medicare people. But what we count on them to do is spread the word.”

Gaines said awareness of health risks is a major factor in Robesonians’ desire to find affordable health insurance. Prevalence of obesity, heart disease and cancer is high in the county; life expectancy is low. Robeson has the highest smoking rate in the state.

The sum is what Gaines calls “the burden of disease.”

Helping people with, or at risk for, cancer is what Gaines does at Southeastern Health and is her primary motivation for combing the community for eligible ACA enrollees.

“We have to partner to survive,” she said.

“It’s very exciting to see,” Schmidt said of the Robeson campaign. It indicates to her that this work is “less about financial resources and more about a strong, collaborative, dedicated effort to get the word out.”

“They really are a shining example not just in North Carolina but nationwide of what you can do with a strong collaborative effort,” Schmidt said.

Francine Chavis assists Sandra McCallum at an enrollment event in Maxton. McCallum’s father owns the barbershop next door to where the event was held. She saw the sign and came in to learn more. Photo credit: Taylor Sisk

Harder to reach

Sampson County – just to the northeast of Robeson and also rural – ranks among the state’s bottom five counties for rate of enrollment. The county is home at least part of the year to a lot of seasonal farmworkers, who tend to be harder to reach.

“But there has been a concerted effort in Sampson to get those workers enrolled,” Schmidt said, with progress made this past summer.

The Benson-based North Carolina Farmworkers’ Project came on board as an ACA facilitator in the summer and has played a leading role in this effort. The organization works primarily with H-2A agricultural workers, and that requires an all-out education effort in the summer.

Mackenzie Mann, a Farmworkers’ Project health educator, said she and her colleagues are often out till midnight trying to reach the uninsured.

Cooperation from growers has been generally good, Mann said. A few have invited educators to come out or have allowed workers time off to attend an enrollment event.

She said there have been no significant differences from county to county in the difficulty of reaching farmworkers; it’s primarily a matter of how well they’ve built relationships with individual worker camps.

“We’ve learned a lot this year,” Mann said, a lot about logistics. Going forward, she said, rather than doing much enrollment over the phone they’ll set up marketplace accounts for as many workers as possible, allowing them to upload documents, saving time and effort.

Something on every visit

Of the 38 federally qualified health centers, or FQHCs, in the state, 35 received federal funding for ACA enrollment.

Elizabeth O. Gilmore, a congregation leader at Dothan Presbyterian Church in Maxton, helped organize an enrollment event at the church. Photo credit: Taylor Sisk

“Number one is building trust,” said Alice Pollard, outreach and enrollment coordinator for the North Carolina Community Health Center Association, “and health centers have built it over the years as the health care home for so many people.”

“We like to say that a consumer never leaves an appointment with an enrollment assister with nothing,” Pollard said. If ineligible for ACA coverage, or unready to sign up, they can be given a referral to an FQHC or another provider in the community, or gain a better understanding of how the ACA works.

Small businesses have been allies for FQHCs in the enrollment effort; child-care centers and pediatric clinics too.

Uncertainty

Many challenges remain.

“The Medicaid gap continues to be an enormous problem,” Pollard said, “especially for rural areas. There are so many consumers who are not able to [get coverage] because we haven’t expanded Medicaid in North Carolina.”

Finding options for these people, she said, is a “huge challenge.”

As for those who are eligible, Vanessa Abernathy said that what’s kept a lot of them from exploring their options is the belief that it’s not going to last: “They’re so afraid that something’s going to happen and it’s not going to be here.”

“My response to that is, ‘Take advantage of it now while you can,’” she said.

“‘At least be seen to learn what’s going on with your body,” Abernathy tells her neighbors.

Her job is to spread the word.

“We just want to say, ‘Do you have health insurance? Do you know about the Affordable Care Act? Would you like to get that information?’ And if they say, ‘No, no, no,’ we say, ‘Can you pass this along to somebody else in your family? Somebody in your neighborhood? Or pass it on to your church?’

“That’s how you get to ‘yes.’”

A national advisory committee finds that health disparities between rural and urban communities have widened. Similar disparities are found in North Carolina.

By Taylor Sisk

A recent report by the National Advisory Committee on Rural Health and Human Services indicates that life expectancy in rural American communities is consistently lower than in urban areas.

The NACRHHS, chaired by former Mississippi Gov. Ronnie Musgrove, provides recommendations on rural health issues to the secretary of the U.S. Department of Health and Human Services. A webinar was held Jan. 28 to discuss the results of its most recent report, “Mortality and Life Expectancy in Rural America: Connecting the Health and Human Service Safety Nets to Improve Health Outcomes over the Life Course.”

Image courtesy Donald Lee Pardue, flickr creative commons

The report’s authors find that while life expectancy at birth for the nation’s population as a whole has been increasing for more than a century, in the past few decades the disparity between rural and urban communities has widened.

In fact, some rural counties have experienced declines in life expectancy during this period. The greatest disparities are found in Appalachia.

Data presented last year by NC Child (see interactive map below) indicates similar disparities in North Carolina.

“This rise in death rates is unique since the flu epidemic of 1918,” Wayne Myers, a committee member and former head of the federal Office of Rural Health Policy, told webinar participants. “There has not been such a large loss of life expectancy of such sustained duration in the industrial world.”

Myers called the rural/urban disparities “an equal opportunity tragedy,” in that they’re found in both majority-black as well as predominantly white communities.

Poverty bound

The committee found that almost all counties with the greatest declines in mortality are rural. From 2005 to 2009, the mortality rate in rural counties was 13 percent higher than in metro counties. (Mortality rate is the number of deaths that occur per 1,000 people in a given place and time.)

Rural/urban disparities in life expectancy also widened, and life expectancy worsened in the most rural areas.

According to NC Child’s data, life expectancy in Wake County in 2014 was 81.4 years; in the largely rural eastern county of Robeson, it was 74.2 years; and in rural Western North Carolina’s Swain County, it was 73.1.

Wake County men lived, on average, 79.3 years; Robeson County men, 71 years; and Swain County men, 70.5.

Wake County women had a life expectancy of 83.2; Robeson County women, 77.3 years; and Swain County women, 75.7.

The NACRHHS report also underscored that as poverty rates increase, life expectancy declines – and more so in rural than in urban communities.

Meanwhile, census data indicates that poverty is on the rise – again, in rural more than in urban communities. The U.S. Census Bureau’s 2013 American Community Survey found that nearly 2.6 million children in rural areas are in families with incomes below the federal poverty level ($24,250 for a family of four).

The child poverty rate of 26 percent in rural communities was up from the 1999 rate of 19 percent. The rate in urban areas rose in that same period from 16 percent to 21 percent.

In Wake County 14.3 percent of children live below the poverty level; in Robeson, the rate is as high as 46.6 percent; and in Swain, 28.8 percent.

‘Older, poorer, sicker’

In its report, the NACRHHS suggests several sources of the rural/urban disparity in life-expectancy rates:

“In general, rural America is older, poorer, and sicker than urban America, all of which contribute to the rural-urban mortality gap. Because rural Americans are on average older than their urban counterparts they are disproportionately represented in the Medicare population.”

In addition, a number of chronic diseases affect rural residents at higher rates. Cardiovascular disease is among them. Smoking is another primary issue.

The good news regarding smoking, said the NACRHHS’s Alana Knudson, co-director of the University of Chicago’s Walsh Center for Rural Health Analysis, is that there has been an overall decrease in the past decade in adolescents who smoke. The bad news is that kids in rural areas are smoking at about twice the rate of their urban counterparts.

Rates of obesity, heart disease and cancer are high in Robeson County relative to the state average and it has the highest smoking rate in the state.

Targeted funding

“By looking at national trends, which are not good, we have missed the fact that some parts of the country are not simply not gaining in life expectancy, they are actually seeing life expectancy decline,” said NACRHHS chair Musgrove.

Throughout the past 25 years, the committee states in its report, the Department of Health and Human Services has addressed access to health care in rural communities by such measures as financing community health centers and providing differential reimbursement for low-volume, rural health care providers.

“However, access to care alone is not enough to fully address complex health outcomes including mortality and life expectancy of populations,” they write. “Approaches must strengthen the health care delivery system while increasing integration of primary, specialty, substance abuse, and mental health services with human services including economic development, employment, housing, transportation, and education.”

Myers reiterated this, saying, “A lot of the issues, I would argue, underlying both the rural/urban disparity and the rising death rates in rural areas are not within the traditional purview of the [DHHS] secretary.”

Efforts to address these issues, he said, must include the secretaries of Commerce, Labor, Justice and Education.

Among the NACRHHS’s recommendations are calls to increase federal support of “research projects that examine behavioral health and primary care integration in rural communities to expand the evidence base for these efforts.” Another recommendation is for the DHHS secretary to direct the National Institute on Drug Abuse to conduct research into the rural/urban implications of opioid use and overdose, including heroin.

The committee also calls for an increase in funding for training primary care providers and emergency medical providers in the use of opioid overdose-treatment drugs, including naloxone.

The report states that while “rural communities face higher levels of health disparities, the funding to address this disparity is allocated on a population basis, leaving rural programs significantly underfunded. The Committee suggests that HHS consider need as a significant factor in future allocation of public health and prevention funding.”

Three North Carolina hospital systems, three strategies, ever evolving.

By Taylor Sisk

At the beginning of this, the final, season of “Downton Abbey,” The New York Times published a mock issue of a 1925 Downton Times, the front-page headline of which asked: “Will Downton Cottage Hospital Be Swept Up in Tide of Change?”

One century and an ocean removed, the fate of rural hospitals remains precarious. Smaller, relatively remote hospitals continue to face numerous challenges: declining, aging populations; dwindling margins; difficulties recruiting providers.

It’s enough to give even the Dowager Countess of Grantham pause.

Granville Medical Center in Oxford. Photo credit: Taylor Sisk

In North Carolina, as elsewhere, rural hospitals are pursuing varying strategies that they trust fit the populations they serve today. Most all consider themselves hospital systems, from small single facilities, such as Granville Health System, to Western North Carolina’s Mission Health.

Serving a broad region

Asheville-based Mission is the state’s sixth-largest system, covering 18 Western North Carolina counties. With the exception of Buncombe, those counties are largely rural.

Mission’s system includes the 552-bed hospital in Asheville and five smaller hospitals: two in Macon County and one each in McDowell, Mitchell and Transylvania. Of those five latter, only McDowell isn’t a critical access hospital.

The system also operates a broad network of primary care and specialty practices throughout Western North Carolina.

The comprehensiveness of this system, said Bob Bednarek, Mission’s vice president for rural health planning and development, affords a “seamless delivery of care” and a “strong relationship with a tertiary center” for some remote, mountainous areas. (The largest town west of Asheville is Waynesville, with a population right at 10,000.)

It’s the kind of system that Jeff Spade, executive vice president of the North Carolina Hospital Association’s NC Center for Rural Health Innovation and Performance, believes is well suited for that region.

“North Carolina is a very diverse state geographically,” Spade said. “You have major urban areas and rural areas geographically dispersed.” By contrast, he said, Kansas and Nebraska, for example, have hundreds of miles of rural terrain within which a large hospital isn’t viable.

Kathy Guyette is Mission Health’s senior VP for patient care services and president of regional member hospitals. Photo courtesy Mission Health

This geographic diversity, he said, lends itself to health systems that have “all the parts you’re looking for,” including a multi-specialty medical center, rural hospitals and community-based physicians.

In most rural areas, Spade said, your major payers are Medicare and Medicaid, with a large number of uninsured, reflecting populations that skew old and very young and often low income. Serving urban areas as well, which are likely to have relatively more privately insured patients, helps keep larger systems out of the red.

“If you can group all that work into a health system, then you can start making the financial resources available across a broad region,” Spade said.

Mission has incrementally brought regional hospitals under its umbrella, and Kathy Guyette, senior VP for patient care services and president of regional member hospitals, acknowledged there’s “always a little bit of that angst” for independent hospitals when joining a system. But that’s generally soon alleviated, she said, by the benefits gained – access to specialists, information systems, purchasing power, career-development opportunities and leverage in recruiting and retaining providers among them.

Mission’s executive team’s immediate focus, Guyette said, is on placing primary care practices throughout the whole of Western North Carolina: “That’s just absolutely the cornerstone. And then we’ll look at what [additional] specialists we need out in our regions.”

Particular needs

Lumberton-based Southeastern Health is a regional system on a smaller scale. It serves all of Robeson County and also has clinics in neighboring Bladen, Cumberland and Scotland counties. Much of its region is distressed: Robeson and Scotland have per capita incomes about $10,000 lower than the statewide average of $25,284; Bladen’s is about $6,000 below.

In 2013, Southeastern Health changed its name from Southeastern Regional Medical Center to signal a shift toward a more comprehensive, out-in-the-community approach to health care.

CEO Joann Anderson of Lumberton-based Southeastern Health. Photo credit: Rose Hoban

Southeastern president and CEO Joann Anderson said the Affordable Care Act “really laid the groundwork that the transition is moving from an inpatient focus to an outpatient focus.”

Unlike Mission, Southeastern has but one hospital. The system includes primary care clinics (including one in a Walmart with evening hours), specialty clinics, a cancer center, behavioral health care services, fitness centers, long-term care, home care, medical equipment services, outpatient rehab services, an urgent care clinic, a weight-loss center and a pharmacy.

And it now has a transitional care clinic with an aim to ease the bumpy road home for recently discharged inpatients.

Southeastern offers everything a multi-hospital system provides, Anderson said. “It’s definitely a system.”

She said that the board of directors has ongoing discussions on whether the system should continue in its current configuration or realign, affiliate or merge. For today, Anderson said, the board feels “we have a good handle” on the needs of a diverse population. Robeson County is roughly 40 percent Native American, 30 percent white and 25 percent black, with a growing Latino population.

Anderson said that in their discussions, analogies have been made to the consolidation of banking, whereby often the specific best interests of a community are subsumed.

“We believe we have the vested interests of the population in hand,” she said, “and that might be lost if we connected with a larger institution.”

A particular service may operate in the red, but is provided if the board feels there’s a need for it and it matches their mission.

“So we find a way to make it work,” Anderson said.

“I won’t say that we’ll never be a part of a larger institution,” she said, “but as long as it makes sense … the board would like to be independently making the decisions about the future of the organization.”

Hometown product

Among the smallest independents in the state is Granville Medical Center in Oxford, 30 miles northeast of Durham. Granville has 62 acute care beds and 80 long-term care. It too is part of a small, locally focused system, Granville Health System, offering a variety of outpatient services throughout rural Granville County.

Lee Isley is CEO of Granville Health System in rural Granville County. Photo credit: Taylor Sisk

Granville CEO Lee Isley has headed the system for 10 years. He said when he first arrived, he went downtown and asked people about their impressions of the hospital.

“One of the things that struck me was that everyone knew the value of the hospital to the community and wanted the hospital to be successful,” he said. While recognizing that you wouldn’t expect anyone to say, ‘Get rid of that hospital,’ his experience is that it’s not uncommon for communities to be indifferent.

Isley knew that such support was vital to the success of a small rural health system.

“I think it’s the history,” Isley said of the source of that commitment. The original building went up in 1938, and is still in use. Community elders tell him they remember playing on the front lawn there on College Street. “There’s a connection with the hospital just through a lifetime worth of experiences.”

Granville County residents, like those of many small rural communities, are proud of their self-reliance, their assets, Isley said. The hospital “defines that they have something of their own.”

When Isley arrived, the hospital employed one physician: a general surgeon; it now has some 20 providers. It also operates the emergency medical system for the county.

An advantage of remaining independent, Isley said, is that those who set the vision and provide the governance are the people who are served.

“These are members of the community. They’re at the grassroots level. They’re committed to the community and the organization, and they want the very best,” he said. “Their energy isn’t split amongst four or five difference facilities over four or five different areas. They’re focused right here.”

Another advantage, Isley said, is that any excess margin “is reinvested in the community; it’s reinvested into our services, into the facilities and into our staff.”

The cons of remaining an independent, he said, include “bench strength.” Those in upper management must be generalists. If, for example, they’re going to introduce the federal 340B pharmacy program, which allows for deep discounts on drug prices, he’ll be involved in that process along with his CFO and COO.

Another con is that while Granville belongs to a group purchasing organization, that still doesn’t give them the negotiating leverage of a large system.

A smaller system allows medical staff to work in a “very intimate, collaborative arrangement. Their voices are heard every day,” Isley affirmed. The downside is, once again, bench strength. Medical staff doesn’t have a great deal of backup; most physicians are single-provider practices.

But partnerships with larger systems in the area help alleviate that. Granville also uses these partnerships – including with Duke, UNC and Wake Med – to access assistance in a variety of specialties.

“We need to know when we need help,” Isley said.

He said the management team and board regularly assess the decision to remain independent, monitoring quality, reinvestment and whether they can provide competitive wages.

“It’s getting tougher and tougher to meet all of those areas,” Isley acknowledged. But, “I’m comfortable that we continue to have an open mind.”

Rural hospital administrators are recognizing that their foremost responsibilities lie beyond the hospital’s doors.

By Taylor Sisk

There are some 2,000 rural hospitals in the U.S. today, and, one could argue, those hospitals face nearly as many challenges to their viability.

North Carolina’s rural hospital administrators find themselves grappling to gain footing in a shifting economic and health care landscape, pursuing paths they trust will lead to solutions to fit the communities they serve.

And, increasingly, meeting the needs of those communities will require embracing the tenets of “population health.”

The main entrance of Carolinas Healthcare System’s Anson Hospital. Photo credit: Taylor Sisk

Population health is a concept that’s gained currency since the launch of the Affordable Care Act, which ties reimbursement to both individual health results and community health outcomes.

There is no precise definition of population health, but it concerns how health care systems, public health agencies and other community-based organizations need to focus on a wide range of factors including primary and behavioral health care, health literacy, public education, personal responsibility, employment, infrastructure and water quality.

Achieving population health goals requires collaboration across disciplines and new ways of thinking about patient care – efforts that hospital leaders will need to embrace in order to remain relevant, and viable.

Solid structure

Jeff Spade, executive vice president of the North Carolina Hospital Association’s NC Center for Rural Health Innovation and Performance, points out that of the six strategies cited in the North Carolina Institute of Medicine’s 2014 Rural Health Action Plan as being critical to improving the health of rural communities, only two are directly related to doctors, nurses or hospitals. The four other strategies cited address investments in local industry, improving child care and education, support for healthy-eating and active-living initiatives and providing consumers with more information about their insurance options.

Jeff Spade says North Carolina has a national reputation as a system-oriented state in its delivery of health care services. Photo courtesy N.C. Hospital Association

But Spade said North Carolina has an advantage: The state has a national reputation as a place where providers already think about care in a system-oriented way.

“We have good, strong, solid health systems, and our rural hospitals, our rural communities, benefit from being part of those health systems,” he said.

N.C. Hospital Association spokeswoman Julie Henry added that another primary factor in advancing this reputation is the support the Kate B. Reynolds Charitable Trust and The Duke Endowment provide for rural health initiatives aimed at broad, population health-based outcomes.

Henry said both are focused on funding alliances that involve “a hospital and other partners in the community or multiple hospitals working together.”

Rural hospital boards, administrators and providers are increasingly aware of the need for such alliances. They’re also aware that keeping people away from the hospital is not only good for the community, it’s good for business.

Rural communities tend to have higher rates of residents who are uninsured, or who have deductibles or co-pays they ultimately can’t afford. They also have higher percentages of patients on Medicare and Medicaid, which reimburse, in general, at lower rates than private insurers.

It pays to keep all of these people as healthy as possible, and it pays to be proactive in the process.

“Our focus, as health care moves forward, is on preventive medicine,” said Fordham Britt, Southeastern Health’s director of physician services. “We want to keep our patients well … keep them out of the hospital.

“Health care is now really in the community.”

Gaining trust

Southeastern is based in Robeson County, where the rates of obesity, heart disease and cancer are high and life expectancy is low. Robeson also has the highest poverty rate in the state and one of the highest in the country.

A high percentage of patients at Southeastern’s clinic in the town of Maxton, said office manager Paula McLean, must consider things that most of us don’t have to factor in when weighing our health care options, like “putting gas in the car and having enough left over for that $3 co-pay.”

Paula McLean says that putting gas in the car is a problem for many of the patients at her Maxton clinic. Photo credit: Taylor Sisk

So Southeastern has clinics located throughout its region with staff that provide essential care, build relationships and educate as best they can.

Dawn Langley, a physician assistant in the Maxton clinic, said many of the medical conditions she routinely encounters are the result of the patient having never been exposed to preventive health services. Meeting her patients’ needs, she said, requires gaining the trust required to allow them to open up.

It’s often not an option, Langley said, to give someone with diabetes an informational brochure or tell them to go online to learn more about their condition. Many of her patients don’t have computers; many are illiterate.

“And they’re hesitant to ask questions because they feel insecure, ashamed, that they can’t read,” Langley said.

Southeastern provides case managers for patients as needed, helping them, for example, find transportation or connect with community-based resources. It also sends staff out to the clinics, on a rotating basis, to assist patients with Medicaid applications.

“It’s really about bringing our health services to the neighborhoods where our patients live,” Britt said, then working closely with social services, the public health department, churches, schools and businesses to leverage all resources within those communities.

Community-wide care

Halifax Regional Medical Center in Roanoke Rapids is likewise reaching out into the community to improve health outcomes.

A 2012 community health needs assessment found childhood obesity had risen in Halifax County from 19.1 percent in 2007 to 21.7 percent in 2009. In collaboration with the county health department, the hospital identified six primary population health concerns and found that obesity was a contributing factor to each.

With funding from Kate B. Reynolds, Halifax Regional helped launch a “Get Fit, Stay Fit Roanoke Valley” campaign, a five-year Roanoke Valley Community Health Initiative that involves education, enhancements to local parks, easier access to healthy foods and workplace-wellness activities.

Granville Medical Center in Oxford, a half hour northeast of Durham, offers another model designed toward seamless, community-wide care, one that a number of rural hospital systems are adopting: a transitional care team.

The team coordinates across departments and agencies to help ensure patients who’ve recently been released from the hospital receive the proper follow-up care. This includes information about community-based resources and self-care and a primary care appointment within seven days of discharge.

The objective, said Granville Medical CEO Lee Isley, is to see that patients are “getting the right care in the right place at the right time.”

And as a means of addressing the health care professional recruitment issue cited in the Institute of Medicine’s Rural Health Action Plan, Granville Medical has a professional service arrangement with UNC Rex Healthcare. The agreement provides Granville’s cardiologist, Richard Pacca, with backup support from Rex – colleagues he can consult with and who step in during vacations.

“We would not have been able to recruit the caliber of physician that he is by ourselves,” Isley said. “That’s why we went with a partnership.”

‘Evolving into something different’

Rural hospital administrators are recognizing that in this shifting landscape it’s no longer possible to offer everything. Rather, the key to survival is providing what’s most needed in the community and making provisions to connect patients with what’s not.

“We’re in charge of the whole health care continuum,” says Cathy Landis, president and chief nursing officer of Transylvania Regional. Photo credit: Taylor Sisk

More than a third of Transylvania County residents, for example, are over the age of 60, and that number is projected to grow. So Transylvania Regional Hospital administrators chose to offer orthopedics and emergency services but not labor and delivery. Expectant mothers are sent to nearby Mission Hospital in Asheville, with which Transylvania Regional is affiliated.

“None of us wanted to give it up,” said Cathy Landis, the hospital’s president and chief nursing officer. “But at the same time, doing it wasn’t the right thing to do when you don’t do enough of it.”

Landis said hospital administrators are now looking at the entire continuum of health care, not just what happens within their walls.

“That’s going to be the challenge of every Hospital USA,” she said.

It takes a system, the Hospital Association’s Henry said, “to ensure that the services are being offered to support the needs of the community even though the hospital may be evolving into something different.”

She cited Transylvania Regional as an example, and Carolinas HealthCare System’s hospital in Anson County as another. The Anson County hospital provides office space for rotating specialists and has a mobile unit that visits churches, schools and businesses to offer screenings, diagnostics and education.

Hospital staff is also training a network of community health advocates to circulate through churches, schools and the county’s major employers, serving, said Gary Henderson, the hospital’s administrator, as “tentacles” to better assess the community’s needs.

This community-oriented approach to health care, Henry said, “really is a picture of the future,” one that ever more rural hospitals are seeking to emulate.

The state Department of Health and Human Services holds its final Medicaid reform hearing – and hears plenty from pediatricians.

By Taylor Sisk

“You really see democracy in action,” state Department of Health and Human Services Sec. Rick Brajer said Monday evening.

He was referring to the series of public hearings his department convened to receive feedback on the state’s impending proposal to move Medicaid from a fee-for-service model to one administered by private managed care companies and local provider-led entities.

Department of Health and Human Services Sec. Rick Brajer said the “strongest voice” in Medicaid reform hearings has been that of pediatricians. Photo credit: Taylor Sisk

Brajer was speaking as an audience of about 75 filed out of Moore Hall Auditorium on the campus of UNC-Pembroke. This was the last of a dozen of those hearings, and he had listened as about 20 people shared their concerns about the future of Medicaid, the state/federal partnership that serves 1.9 million children, some of their parents, people with disabilities and the elderly in nursing homes – roughly one in five North Carolinians.

Those who spoke on Monday were almost all health care professionals, were unfailingly respectful and shared many of the same anxieties: Will privatized managed care result in restricted care? Will it provide for flexibility? Will CCNC – the state’s current not-for-profit Medicaid management system – be a part of the new system?

Some expressed what DHHS officials have heard repeatedly throughout the state: that Medicaid expansion is critical to the success of any statewide health care plan.

And from a number of pediatric providers came pleas to be particularly careful not to allow reform to harm children.

Christoph Diasio of Sandhills Pediatrics noted that kids comprise some 60 percent of the state Medicaid program’s enrollees but a considerably lower percentage of its costs.

“Children ought to be left out of this waiver,” Diasio told Brajer.

Provider supports

The federal Centers for Medicare and Medicaid Services pays two-thirds of the cost of North Carolina’s Medicaid program, and state officials must thus gain its approval for any changes to the program.

Mac Legerton, a Robeson County minister, called on Brajer to convene representatives of the state’s “poverty pockets” to form “a learning community, as a partner, not as an adversary, with DHHS.” Photo credit: Taylor Sisk

The plan the state will be presenting to CMS is called an 1115 waiver to the Social Security Act of 1965, the law that created Medicaid. The intent of the overhaul is to both save money and encourage innovation.

The waiver will be submitted June 1, at which point a lengthy back-and-forth with CMS will commence. It could be several years before the waiver is even approved, and another one to two years before the public sees any changes.

“We’re going to continue to listen and innovate,” Brajer told Monday’s audience. “This is an ongoing discussion between ourselves and CMS and between ourselves and the rest of the state, especially on the issues that are maybe the most contentious.”

Brajer said the plan will transition health services in the state from what’s now termed the “triple aim” of health care – a more satisfactory patient experience, improved health outcomes and lower per-capita costs – to a “quadruple aim,” with the addition of a focus on provider supports.

These supports, Brajer said, would include assistance with “administrative burdens.”

He said that in drafting the waiver, DHHS has engaged some 50 associations from throughout the state.

“If there’s an association that we didn’t talk to, I’d love to know what their name is,” he said, “because we spent a lot of time with a lot of folks in developing this waiver.

“It would probably be closer to being true to call it a crowd-sourced waiver,” Brajer said, “It reflects the input of a lot of folks.”

He said that a primary objective is to offer beneficiaries more choice. They will have the option to choose from up to three statewide and two regional plans, with contracts that will run for four or five years. Behavioral health services will not be included in the waiver for at least four years.

Brajer said the state will offer plan enrollment assistance on request.

‘The Kids Sent Me’

“Without a doubt, the strongest voice has been by pediatricians in terms of the challenges they face from a rate perspective, from a systems’ perspective,” Brajer said, summing up the input received from the hearings.

Christoph Diasio of Sandhills Pediatrics told Brajer that, “Children ought to be left out of this waiver.” Photo credit: Taylor Sisk

“If you’d told me prior to the public hearings that the loudest voice in all these meetings would be pediatricians – loudest in terms of the most frequently heard – I wouldn’t have predicted that,” he said.

Pediatric providers certainly played a prominent role in Monday’s discourse. Among them was Sandhills Pediatrics’ Diasio, who wore a “The Kids Sent Me” button.

Diasio said that in his role as chair of the American Academy of Pediatrics’ Section on Administration and Practice Management, “I’ve been unable to find a single pediatrician, nationwide, who has nice things to say about managed care Medicaid. They envy what we do in North Carolina … impressed with the good work that CCNC does.”

“Children in North Carolina are not where the cost is,” Diasio said, urging that kids not be included in the managed care waiver.

Rural needs

Asked how, if at all, input differed in a rural area such as Robeson County, where the UNCP campus is located, from that received in the hearings held in cities, Brajer said, “What you hear more about are the social determinants of health, how the economy impacts health.”

Cherry Maynor Beasley, a professor in UNCP’s department of nursing, a nurse practitioner and a member of the Lumbee tribe, shared some of those concerns during the hearing, discussing “health, place, wealth and race.”

Cherry Maynor Beasley, a professor in UNCP’s department of nursing, stressed the importance of hearing from rural communities in shaping Medicaid reform. Photo credit: Taylor Sisk

Beasley said that 47 percent of children in Robeson County live in poverty, the infant mortality rate is nearly double the state average and twice as many children are born to mothers who don’t have a high school education.

She stressed to Brajer the need for a plan that includes a greater emphasis on health education and incentives for inter-agency collaboration. Beasley said that rural communities should be actively engaged in the reform process to determine the services that best meet their particular needs.

Brajer said his department was also consistently hearing from rural residents about the need for incentives to retain or attract health care providers, mentioning, in particular, OB/GYNs and psychiatrists.

“Workforce development becomes more important in an environment like this,” he said. He added that his department will be proposing to the legislature “taking graduate medical-education dollars and reorienting them … to needed providers in rural areas.”

That proposal, he said, is “teed up for the short [legislative] session.”

By Minali Nigam

The eyes have it in this year’s Senate budget, which calls for $2.1 million to fund adult eye exams.

“We have reinstated [that] coverage so that we can continue to find glaucoma and diabetes and other vision issues that exist in the Medicaid population for adults,” said Senate Health and Human Services appropriations co-chair Ralph Hise (R-Spruce Pine).

Photo courtesy Andrew Fresh, flickr creative commons

Sen. Gladys Robinson (D-Greensboro) asked during a Senate appropriations meeting Wednesday whether the coverage would extend to treatment for people who are diagnosed after the routine eye exam.

Only the exams would be covered for adult eye issues, Hise conceded, adding that funding for follow-up services would be considered in the long run.

Even with the coverage, having all those eye exams performed could pose problems. According to 2014 health workforce data from UNC-Chapel Hill, twelve counties in North Carolina have few or no optometrists.

“Our ratio of optometrists to the population is low,” optometrist Dr. Hal Herring told legislators during a 2014 hearing.

That meeting brought lawmakers and optometrists together at the General Assembly to discuss provider practice, training, and the current state of optometry in North Carolina. Since Herring spoke at the legislature, there’s been little discussion about optometry training in North Carolina.

Until now.

The current Senate budget would also make moves to alleviate an optometrist shortage. Senators’ spending plan supports a study on creating a training school at Wingate University, in Union County.

“There are no schools for optometry in the state,” Sen. Tommy Tucker (R-Waxhaw) said during this week’s appropriations committee meeting. “Optometrists are aging out.”

The optometry program would be funded privately by Wingate, according to Tucker, but the state would put $900,000 towards establishing a free clinic so students could get experience while treating Medicaid patients.

The phoropter is the most recognizable tool used by optometrists, used to determine a person’s eyeglass prescription.
Photo courtesy woodley wonderworks, flickr creative commons.

The plan encourages Wingate to assess the number of potential applicants and expenses for the program.

“No money has actually been appropriated; it’s just a study for the State to get the numbers,” Tucker said.

Herring told lawmakers in 2014 that national figures show roughly one optometrist per 7,000 persons. “In NC, it is closer to one optometrist for every 10,000 of the population,” he said.

Herring’s practice is in Robeson County, one of the shortage areas.

“If we had a school of optometry in North Carolina, we feel like that would be beneficial to our ratio of optometrists to population over the coming years,” he told lawmakers at the time.

Students from North Carolina who want to attend optometry training programs have to go out of state and pay out-of-state fees. Herring said that students who leave to be trained tend not to return to the state to establish their own practices.

Doc makes it his mission to bring subspecialists to rural southeastern North Carolina.

By Taylor Sisk

Fernando Moya, requires little sleep – which is fortunate, given that his days are stretched pretty thin.

Moya, a neonatologist, is founder, president, and CEO of Coastal Children’s Services, a pediatric subspecialty group. The practice is based in Wilmington, but, by design, has no stand-alone offices of its own. Moya’s objective in creating Coastal Children’s Services was to enhance quality neonatal care in Wilmington and then reach out into the largely rural southeast, placing neonatologists and other pediatric subspecialists where they’re needed most.

In additional to its offices at Wilmington’s New Hanover Regional Medical Center, the practice now has pediatric specialists in four hospitals in the region: Onslow Memorial Hospital, Camp Lejeune Naval Hospital, Southeastern Regional Medical Center, and Columbus Regional Healthcare System.

Fernando Moya’s objective was to enhance quality neonatal care in Wilmington and then reach out into largely rural southeastern North Carolina.

On a recent Tuesday morning at Southeastern Regional in Lumberton, Moya is clutching an extra-large cup of Dunkin’ Donuts coffee and sporting a day’s growth of stubble. He’s just had, he allows, “a rough night” in the neonatal ICU. But he’s eager to discuss his ambitions for pediatric care here in Robeson County, a county with the state’s lowest median household income, at $30,248, and some of its worst health indicators.

Coastal Children’s Services has been providing care at Southeastern Regional since August of last year. Moya hasn’t yet hired someone to oversee operations here, so he’s still very hands-on. But that’s his modus operandi anyway: right in the thick of things. He spends a few days each month practicing throughout the region.

“I like to be here because I like to try to bring the enthusiasm of what we’re trying to do,” Moya says. “I enjoy it.”

An opportunity to make a difference

A native of Chile, Moya began his pediatric training there and completed it at Yale. He remained on faculty at Yale for 6 years, served as associate director of neonatology at Louisiana State University and then chief of the division of neonatal-perinatal medicine at the University of Texas McGovern Medical School in Houston.

In 2005, he was recruited to come to Wilmington. Negotiations had begun to build a children’s hospital at New Hanover Regional, and Moya was attracted by the opportunity to bolster neonatal care in the area. He now serves as associate director of neonatology at New Hanover Regional and medical director of the Betty Cameron Children’s Hospital.

At the time of his arrival, the nearest NICU was in Fayetteville, nearly 100 miles away. Moya began to plot a regional strategy, with New Hanover Regional as the hub and Level 2 NICUs in the surrounding more rural areas.

Alan Stiles, UNC Health Care system’s vice president for Network Development and Strategic Affiliation and former chair of pediatrics at the N.C. Children’s Hospital, says that what Moya is providing was much needed.

“The southeastern region of North Carolina mainly has smaller rural hospitals with limited capacity to do more than stabilize and send premature or sick newborns to larger hospitals, often at great distances from their families and home,” Stiles says.

According to research conducted by NC Child, in Orange County — home of the UNC Health Care system — there are 3.4 infant deaths per 1,000 live births and life expectancy at birth is 81.7 years. In Robeson County, only a 2-hour drive away, there are 13.4 infant deaths per 1,000 live births and life expectancy at birth is 74.2 years.

Providing care where most needed

Moya founded Coastal Carolina Neonatology in 2009. His first regional alliance was with Onslow Memorial in Jacksonville, an hour from Wilmington.

In May 2010, he launched a broader initiative, Coastal Children’s Services, an LLC, which today employs 25 physicians and about the same number of advanced practice clinicians. Pediatric subspecialists now practice either in the hospitals or in already established practices throughout the region.

“Our vision has been to bring the care to [the hospitals], help them elevate the level of care, and keep as many patients as they can there,” Moya says. “We’ll support them locally. Whatever cannot be managed there will go either to Wilmington or elsewhere, with the appropriate triaging.”

Stiles, who calls Moya a “highly accomplished neonatologist and academic leader,” emphasizes the importance of the relationships with academic medical centers that Moya has forged to ease transfers when necessary.

Joann Anderson, president and CEO of Southeastern Regional and past president of the American Hospital Association’s Small and Rural Hospital Council, has embraced Moya’s initiative: “With Dr. Moya’s help, our staff is learning to care for more complex health care issues in neonates.

“By doing this, we’re hoping to be able to keep the infant near its support family while potentially improving outcomes because care is more readily accessible.”

Results take time. But according to NC Child data, the number of children up in Onslow County (where Moya formed his first alliance) receiving early-intervention services in their first 3 years rose by 45 percent from 2009 to 2013.

How it works

Making this work, Moya says, entails several critical elements.

First, “we recruit extraordinary people who can multitask.” That means, for example, that Janet Hoffer, who handles marketing and PR, also assists with education initiatives. It also means an all-hands approach to administrative duties.

Second is keeping overhead low. Being based in hospitals and established practices helps considerably in that effort.

Moya says he negotiates “reasonable contracts” with the hospitals, providing a number of services at cost. “It would be very hard to try to milk a lot of resources out of hospitals that are struggling,” he says.

Education and research

Coastal Children’s Services is also cultivating alliances beyond the region. The University of Chicago Medicine Celiac Disease Center, for example, has provided training, and Moya hopes to establish his practice as an affiliate.

He and his colleagues host three annual conferences, offering “world-class” speakers, Moya says. A recent symposium speaker was Richard Polin, MD, a member of the American Academy of Pediatrics’ Committee on Fetus and Newborn and co-author of the widely used Workbook in Practical Neonatology.

Hosting such events, Moya says, is central to the mission: “We have the connections, we have the insight, we have the motivation. And we also learn ourselves.”

The practice also conducts clinical research — both its own and in multi-center trials — and New Hanover Regional is now a member of the Pediatric Trials Network.

Unacceptable outcomes

North Carolina’s infant mortality rate (in 2014, 7.1 deaths per 1,000 live births) has consistently been among the nation’s highest. It’s considerably worse in the southeastern region of the state.

Moya believes that in an area so close to nationally recognized medical centers, including UNC and Duke, such outcomes are unacceptable.

“We hope to be a vehicle to summon that collective strength,” he says. For that to happen, “We need to partner with others, improve access to general care, then some specialty care. And then let’s try to recognize the time needed to interact, educate, and improve quality — and then see where those rewards go.”

“When he approached me about collaborating, he described his vision and reasons for it,” Southeastern Regional’s Joann Anderson says. “He told me he believed a regional approach to issues related to infant mortality was needed.

“I fully support that vision.”

By Thomas Goldsmith

North Carolinians from Buncombe County to Little Washington, with a stake in the consumer side of mental health care, had some sharp questions last week for the state Department of Health and Human Services about coverage provided by state- and Medicaid-funded managed care organizations provide.

The occasion was the monthly meeting of the state Consumer and Family Advisory Committee (CFAC), an oversight body that has corresponding committees across the state.

The committees provide mental health care consumers and their relatives with oversight of state government-funded care that’s coordinated by North Carolina’s seven local management entities, known as LME-MCOs.

“The State CFAC shall be a self-governing and self-directed organization that advises the Department and the General Assembly on the planning and management of the State’s public mental health, developmental disabilities, and substance abuse services system,” the statute establishing the committee reads.

Members met at the Brown Building on the Dorothea Dix campus, the grounds of the former state psychiatric hospital that closed in 2010. The state sold the campus to the city of Raleigh for $52 million, with some of the proceeds are earmarked for mental health programs.

Then there were four

State DHHS officials announced in March that the then-eight regional LME-MCOs would be consolidated into four. CFAC members heard from state officials on a variety of initiatives in the mental health field, and several expressed concerns that constant changes could upset the system.

North Carolina DHHS official Dale Armstrong addresses the August meeting of the statewide Consumer and Family Advisory Committee on behavorial health issues. Photo credit: Thomas Goldsmith

“It frightens to me to think of the people that are going to wind up in the ER again,” said state committee member Marie Britt, of Lumberton. “We are taking away what was basically a stable situation.

“So, what are we going to do? Is there somebody talking, somebody planning?”

In a follow-up interview, Britt said her concern arose from changes that seem to occur regularly in the state’s system of behavioral health care: This time, it’s the coming consolidation down to four LME-MCOs, the transfer of substance-abuse centers to LME-MCOs, and a new requirement for higher levels of certification for nurse practitioners to treat people with severe mental illness.

She said she was encouraged by some of the new crisis-management techniques the state is undertaking.

The committee appears to be attracting attention from lawmakers for some comments from families about the existing system. Five legislators have said they will attend next month’s meeting.

But for Wednesday’s meeting, Dale Armstrong, DHHS deputy secretary of facility-based behavioral health/developmental disabilities services, answered questions at length.

How well, members asked, will it work to transfer substance abuse services to the LME-MCOs?

“Personally, I think it’s going to be a challenge, because the current legislation has some gaps that no one would have anticipated that need to be addressed, related to how do you operate a facility whose primary population is indigent,” said Armstrong, who oversees 14 state facilities.

Some attendees at Wednesday’s meeting seemed more focused on the overall quality of care than on changes in the system.

“Whether we are 23 counties or whether we grow, people should get the help they need when they need it,” state CFAC member Pat McGinnis, of Marion, said in a follow-up interview.

McGinnis is also a local member of the Smoky Mountain LME-MCO community and family advisory committee.

The state’s overhaul of mental health care has since 2010 increasingly relied on state-backed managed care organizations to care for people who have problems with behavioral health, intellectual and developmental disabilities, and substance use. The LME/MCOs (local management entities/ managed care organizations) receive a fixed rate for clients, and make money if they spend less than the allotted amount.

Renee Rader, waiver program manager for the Division of Medical Assistance, said the state has renegotiated its contracts with the LME/MCOs to make sure the companies aren’t spending too large a percentage of revenue on administration, as opposed to program costs.

One more question came from board members: Who oversees the LME-MCOs?

Armstrong said that another official who deals with community-based care could better answer the question. But according to state law, the committee itself is tasked with a key part of that duty.

Looking back at the years before the state took on behavioral health reform, committee chairman Kurtis Taylor said that North Carolina has accomplished much in the mental health field. He specifically cited the money that is coming to the mental-health care sector as a result of the Dorothea Dix sale.

“If God opens the door, we are going to walk right through it,” Taylor said.

There’s little research on how mom’s with newborns in the NICU cope. But by all accounts, their needs are being ignored.

By Thomas Goldsmith

After a woman gives birth, the spotlight tends to shift to the newborn, sometimes leaving the mother herself in need of critical help even as she cares for her baby.

Dr. Alison Stuebe, associate professor of maternal-fetal medicine at the UNC-Chapel Hill School of Medicine, doesn’t pull punches when she discusses how a new mother’s needs can be neglected when babies end up in neonatal intensive care units, or NICUs.

When babies are in the NICU, moms often find they are not getting their own needs met. Photo credit: Michael Bentley, flickr creative commons

“In all of perinatal care, once the baby is out, everyone’s focused on the baby,” she said in an interview, noting that she is deliberately offensive putting it another way.

“Once the candy is out of the wrapper, the wrapper is cast aside.”

Stuebe is lead investigator in Care4Moms, a federally funded, $900,000 study of the situations of mothers with medically fragile infants. Researchers in the interdisciplinary team, led by the UNC Center for Maternal and Infant Health, say that this population of mothers is significantly understudied.

The Care4Moms study involves 7,000 women who gave birth at the North Carolina Women’s Hospital during a two-year period. Researchers will analyze the care mothers of fragile infants received compared to mothers of children cared for in the well-baby nursery.

“Mothers of medically fragile infants must recover from birth while at the bedside of a critically ill newborn,” Stuebe said in press information. “These challenges are compounded by the fact that data suggest these women are more likely to have birthed by C-section and experienced complications and may have underlying chronic health problems, such as high blood pressure and diabetes.

“Moreover, many mothers of medically fragile infants live hours away from where their infants are hospitalized.”

For example, Stuebe said in the interview, a mother with a sick child who is cared for in UNC’s NICU may have to commute a couple of hours to and from Robeson County to be with the infant. All sorts of other complicating factors can affect women in this situation, she said.

“Of the moms with a baby that stays in NICU for more than three days, half have delivered by C-section and they are discharged on day four,” she said.

“It’s a really, really fraught situation, Even if you live 10 minutes from the hospital, you still can’t drive. Even if she had a vaginal birth, she may have a laceration. Her milk is starting to come in and she’s trying to figure that out.”

Other family members, however eager to help, may themselves face real obstacles.

“I think dads absolutely are struggling as well,” Stuebe said. “They may be home with the other kids. And they’re trying to be there for her and for the baby.”

Several participants in the Care4Moms study, including Sarah Verbiest, director of UNC’s Center for Maternal and Infant Health for 11 years, have a long track record of advocating for patient-centered, team-based best practices for mothers and infants.

“The team supports families through the highly emotional and complex world of prenatal infant diagnosis, prognosis, treatments, and specialty services,” Verbiest wrote in “Starting Life with Coordinated Care,” an article in the March/April 2009 edition of the North Carolina Medical Journal. “A primary goal of the program is to help parents learn how to navigate the health-care system and become advocates for themselves and their babies.”

Verbiest is also principal investigator on what’s known as the 4th Trimester Project, a UNC effort to bring together mothers, health care professionals and others with a stake in the issue of mothers’ health needs that may be neglected during the first three months after a baby is born.

Both Care4Moms and the 4th Trimester Project are concerned with issues such as breastfeeding issues, mood disorders after birth, infant sleep practices, incontinence, a return to tobacco use and inability to receive affordable contraception.

Some of the ideas that are emerging as the study continues this fall:

• Identifying the specific health problems experienced by mothers of medically fragile children.
• Having a nurse visit the home of the postpartum mother to check her health status.
• Assigning a UNC hospital medical health number to the mother when the baby is admitted for treatment, making it easier for the mother to receive postpartum care.

Project researchers will interview new moms of medically fragile infants about how well the health-care system serves them and their babies. The team will also interview UNC doctors, nurses and other providers to get their takes on what’s being offered mothers — and the services that aren’t available, but should be.

“Our hunch is that these moms wind up in the ER,” Stuebe said. “There hasn’t been a lot of work in this area. There’s a tremendous amount of attention paid until the baby’s out of the wrapper.”

Hurricane Matthew flooding will produce multiple hazards at home, indoors and out. Accurate information and time are required to help families cope.

By Catherine Clabby

There’s little worse than the vast flooding Hurricane Matthew has unleashed in North Carolina. Dirty water has breached homes, storefronts, nursing homes. People have been trapped in cars stalled in rushing water. Death tolls are rising.

But as people of this coastal state know too well, the trouble will not fade when Matthew’s floodwaters recede.

A rising crest of health threats is also on its way, public health experts say, including some unexpected risks. Families already battered by flood damage need to take steps to protect themselves all over again.

After flooding from Hurricane Irene in 2011, some North Carolinians had a big clean up on their hands. Sea Level, NC, Sep 7 2011 –Flood damage from Hurricane Irene. FEMA photo/Tim Burkitt

“People get very concerned about dirty water, that fuel oil might have leaked or sometimes their septic tanks. In reality, most of that doesn’t pose much of a health risk,” said Dr. Julie Casani, head of the state public health division’s Public Health Preparedness and Response branch.

“I worry more about people getting injured during the cleanup.”

Floyd, Fran and friends

Experience from previous storms backs that up. After a flood, homes that normally are shelters become altered environments hosting all sorts of hazards, contributing to an expected post-flooding uptick in emergency department visits.

For six weeks after Hurricane Floyd struck in 1999, incidence of bone and tissue injuries, respiratory problems, gastrointestinal trouble and heart disease were higher at 20 hospitals in 18 counties than they were over the same period the previous year.

Suicide attempts, dog bites, fevers, skin problems, and people seeking help with basic medical needs such as oxygen and medication refills, dialysis and vaccines all were more common during the six weeks after Floyd. So were spider bites, diarrhea, asthma attacks and injuries from assault, gunshot wounds and rape.

People can take steps to protect themselves. To begin with, people should stay clear any water that is slow to drain, said John Morrow, PItt County public health director. Its depth can be deceptive and may pose a drowning risk, the most common cause of death from floods.

“Just stay out of the water, period. Particularly children,” Morrow said. “They are too likely to say I’m just going to swim out there and get my ball.”

The exhaust or fumes from a portable generator could kill you in minutes if you breathe it in. Image courtesy the Centers for Disease Control and Prevention.

Casani agrees. “You can’t see what you can’t see. While plodding through water you may not be able to see something that is submerged. People can get cut. Or they trip and fall or sprain an ankle.”

Air it out

During a flood cleanup, people sometimes bring petroleum-powered devices — generators and power washers included — inside their homes or garages. That should never occur, Morrow said, because the carbon monoxide emissions can be deadly.

“Exhaust collects. Before you know it, you get dizzy and can’t get to fresh air or turn the thing off in time,” he said.

Ten cases of carbon monoxide poisoning were reported in weeks after Hurricane Floyd, compared with none during a comparable period in the previous year.

There is plenty to do indoors. And while water laced with chemicals or sewage is not the biggest threat people will encounter while cleaning up their homes, that remains a potential risk. So cleaning with protective gloves and boots is recommended.

“You don’t want flood water to come in contact with your face or mouth. The risk of sickness is low. But pathogens can pass through cuts and scrapes,” said Tim Kelley, the director of the environmental health program at East Carolina University.

After a flood, wall board needs to be removed and mold treated with bleach and other cleaners before rebuilding can recur. Photo credit:
Angela Schmeidel Randall, Flickr Creative Commons

The North Carolina State University Extension offers detailed guidance on how to proceed with cleanups at home after a flood. A priority is to shovel out mud or silt before it dries and to wash down flooded walls and floors with hoses and then get them dry.

Drywall acts like a sponge, extension materials warn, and it might be necessary to remove wall board above the flood line. Wet insulation also must go. Sometimes holes must be drilled into the siding to fully dry walls, a process that can take months.

Much of that effort is required because of mold growing inside a home. Mold isn’t a health risk to everyone, but it can be a serious risk to people with asthma and allergies, or people with suppressed immune systems due to HIV infection, cancer treatments or other health conditions.

“One of the things about eastern North Carolina is that we’re surrounded by mold. You can’t avoid it, it is so damp and musty. There are thousands of species,” said Paul Barry, from the Department of Public Health at ECU.

The state Department of Public Safety recommends people treat every item touched by floodwaters as contaminated and disinfect those items with household cleaning products. It also recommended that people stay clear of any flood-damaged material that may contain asbestos. Discard mattresses, upholstered furniture, carpets and padding, and books and paper products touched by floodwaters, department officials urge.

Choose caution

Then there’s food and drinking water safety to attend to.

Updated information on water system advisories is hereState Health Director Randall Williams on Tuesday urged people in multiple counties to boil their water, including portions of Bladen, Carteret, Chatham, Chowan, Columbus, Cumberland, Currituck, Dare, Duplin, Franklin, Hertford, Hoke, Johnston, Lenoir, New Hanover, Onslow, Pender, Perquimans, Robeson, Sampson, Wake, Wayne and Wilson counties.

Image and content courtesy Centers for Disease Control and Prevention

When it comes to food, be conservative, health officials say. Discard any food touched by floodwaters, including edibles in cans, bottles or jars. Food that was in a refrigerator or freezer that reached more than 40 degrees should be thrown away, the N.C. State University Extension materials recommend.

If all the above isn’t enough, there are also disease-carrying insects to worry about. Mosquitoes lay their eggs in water and multiply more quickly after big rains and floods. State health officials recommend people wear insect repellent and empty any standing water in birdbaths, tires, flowerpots and other containers.

Casini, who lost a home to damage from Hurricane Isabel in Maryland in 2003, stressed that natural disasters, and all the challenges that follow, put a strain on anyone’s mental health.

She encourages people to slow down and not try to put everything back together at once, indoors or out.

“This isn’t your standard fall cleanup. This is happening in treacherous conditions,” Casini said.

Instead, do only what is feasible to tackle safely, she said. Try to get your family on what feels like a normal schedule. And reach out to other people in the same boat.

“Maybe they were never your friends,” Casini said. “But something like this becomes a collective experience.”

Hospitals throughout the eastern part of North Carolina have been affected, but none more than Southeastern Regional in Lumberton.

By Rose Hoban

On Saturday, as Hurricane Matthew’s eye scraped the southeastern-most edge of North Carolina, the power went out at Southeastern Regional Medical Center. But Joann Anderson, the CEO of Southeastern Health, which has it’s flagship at the Lumberton hospital, was ready.

Many medical workers have lost homes in the flooding around Robeson County, according to Southeastern Health CEO Joann Anderson. Photo credit: Press office, Gov. Pat McCrory

Hospitals are required to have generators for just such an occasion, but in anticipation of a “water event,” Anderson’s management team had asked many staff to stay.

“I have had nurses and other staff who have been here since Friday and have not been home, I have many people who are working and can’t get home,” Anderson said by phone Wednesday. “Their houses are in the flood area and they can’t get to them.”

Many of Anderson’s staff have had trouble making it to work. Floodwaters surround downtown Lumberton where the hospital is located, effectively making the downtown an island.

“We have a number of employees who have attempted to get into work and can’t,” she said. “We’ve had others who would have taken 30 minutes to get here and it’s taken hours, they’ve had to go very convoluted routes to get here.”

And finally, others have come in because they have nowhere else to go.

“We have others who were boated out or rescued, or evacuated prior to the flooding occurring, they know they’ve lost their home, but they’re here with a smile on their face and taking care of people and just being thankful that they have a place to work and that they’re safe,” Anderson said.

She laughed. On the other end of the line, one can imagine Anderson shaking her head.

“It’s been a time…”

Power, water, internet

Anderson was doing her first interview in days because she has been working almost steadily to keep the hospital going. Also, the Internet was down until Wednesday morning and other forms of communications were spotty.

Aerial view of flooding around Robeson County. Many medical workers have lost homes in the flooding around Robeson County, according to Southeastern Health CEO Joann Anderson. Photo credit: Press office, Gov. Pat McCrory

“We’re finally digging through emails we’ve received,” she said. “The landline was necessary and we’ve had to depend on our cell phones as much as possible, but service has been sporadic.”

Being offline was the least of Southeastern Regional’s problems, though. The generators that are keeping refrigerators humming and surgical lights shining can overheat and fail, much like a barely used car doing a high speed, cross-country trip. Twice.

Anderson said that one generator failed Wednesday morning. Luckily, state officials supplied them with a temporary generator. A press release from the hospital Wednesday morning noted excessive diesel exhaust outside the facility.

But Southeastern’s biggest problem is water, or lack of it: The water treatment plant in Lumberton, which supplies the city and the hospital, is under water.

“We lost that, I believe, on Monday,” Anderson said, noting the days have run together.

Hospitals use a tremendous amount of water, from hand washing to flushing nasty bodily fluids down the drain, to cooking, sterilizing surgical equipment, and performing most laboratory tests.

“For instance, we have no sprinkler system, we had to put in a manual fire watch,” Anderson said. “We have people roaming the building looking for fires so that we would manually see it, because we have no other way to catch a potential threat. That’s a continuous fire-watch situation.”

And, with no municipal power and no municipal water, there only way to flush a toilet is by hand.

“We’ve had to have staff going from bathroom to bathroom to bathroom, flushing commodes, manually, using a bucket of water and pouring it into the commode to flush them,” she said.

Anderson said the main hospital had deployed a temporary water treatment plant that is currently supplying potable water to about half of Southeastern Health’s main campus. But there’s still issues at the long-term care facilities operated by the network.

“Just the human resource needed to handle those needs has been tremendous,” she said.

The hospital has evacuated many critical needs patients to other facilities.

Community support

North Carolina Hospital Association spokeswoman Julie Henry said the hospital is lucky to have Anderson, who’s been at the helm of rural hospitals for two decades.

“I’d be surprised if she’s slept,” Henry said.

Henry, who has experience handling natural disasters from her time at the state Department of Health and Human Services, said that, flooding is probably the worst crisis for hospitals.

However, the state hospitals have a system of mutual aid during disasters that has been in effect for the past week.

“From our perspective, the number one goal was to help the state officials assess the situation,” Henry said. She explained that much of the response is lead by the Division of Health Services Regulation and the Office of Emergency Medical Services, offices that have been through disasters before.

“Several folks I’ve talked to have mentioned what we learned in Floyd,” Henry said, noting that these situations are why hospitals run tabletop and real-time disaster drills several times a year.

“A couple of CEOs who have been around since Floyd said the things they learned… have helped, if not in the preparation, at least in the recovery,” she said.

Carolinas MED-1 travels as two 53-foot tractor trailers plus other support vehicles and can be operational within 30 minutes of arrival at the site. The facility is completely self-sustaining for the first 72 hours using generators and 72 hours of Emergency Department supplies travel with the fleet. The unit is equipped and staffed to manage minor to severe emergency medical conditions, including operative trauma surgery and intensive medical care. Photo courtesy Carolinas HealthCare

Anderson and Henry both said state officials have been very responsive to needs, as well other hospitals via those mutual aid pacts. Southeastern has an agreement with Charlotte-based Carolinas HealthCare System, which deployed their mobile emergency/operating room, Med-1, to Lumberton. It arrived Tuesday.

“We’ve had offers from Columbus Regional, from Cape Fear Valley, from FirstHealth, from Duke, Novant,” Anderson said. “On a regular business day we might be in competition with each other, but that just went out the door, and we’re all in health care, and we’re all taking care of people, and tell me what you need and we’ll make sure you’re taken care of.”

Then there’s the local community. Anderson said her people put out an appeal on Facebook and on the hospital website for nurses and other licensed professionals to help give her own staff a break.

“We’ve had tremendous response from the community, overwhelming,” she said. “The phones were flooded within no time. We have three pages of names of people, nurses and others, who have just said, ‘Tell me what you need, when you need me to work and I will be there.’”

Damaging flood waters steal so many things, including the reliable drinking water supplies people usually take for granted.

By Catherine Clabby

If the floodwater would get out of his way, Rob Armstrong could get on with the job of restoring drinking water to the battered city of Lumberton. But that is going to take time.

Water utility managers further east expressed fear of situations such as this one in Smithfield, where water mains running underneath roads fail in the wake of flooding. Photo credit: Heather Parker Shortt/ Facebook

“We’ve got four feet of water over our only treatment plant. It’s damaged quite severely at this point,” the city’s public works director said Thursday.

Not only is the power grid down in the Robeson County city, so is a drowned back-up generator at the plant. Equipment used to sanitize drinking water and extract sediment is very likely damaged too. No one knows how many busted water pipes are waiting to be discovered in a system 20,000 people are sorely missing right now.

It’s the cruelest of ironies. When floods deluge towns and cities they frequently disrupt public drinking water supplies. So it’s been in Eastern North Carolina where Hurricane Matthew’s rains have raised multiple waterways to record-breaking levels in the Neuse, Cape Fear and Lumber river basins.

More than 30 water systems,in flood-stricken zones in eastern counties as of Thursday (down from 40-plus on Wednesday) were recommending that customers boil their tapwater. Water system managers do that when bacteriological contamination may have breached a water supply until testing can confirm the water is safe.

Floods raise that risk because rushing water is muscular enough to damage underground water pipes, potentially exposing drinking water to pathogens and other contaminants. “In a lot places, roads got washed out. We run water lines adjacent to those roads and bridges,” said Chad Ham, the Environmental Programs Manager at Fayetteville Public Works Commission.

Water systems don’t always know when or where a length of pipe is broken during a flood. But the loss of water pressure is an alarm bell.

Under pressure

Pressure problems started in Fayetteville’s network of water pipes on Saturday night, while Hurricane Matthew was still pelting Eastern North Carolina with heavy rain. “In parts of the systems where elevations are higher, we could not maintain sufficient pressure. It got very low and in some cases there was none at all,” Ham said.

In addition to the system’s boil-water advisory, Mayor Nat Robertson declared a “water shortage crisis” in Fayetteville.That required citizens to use water only for essential needs, such as drinking water for themselves and their animals, minimal cleaning, medical care, firefighting and other necessities.

Finding and sealing off a broken 22-inch mainline pipe on Sunday helped the situation. By the next day, public works crews had found others, shut them down, and could start restoring pressure.

Next crews flushed the water lines, pumping up the pressure higher than normal to expel, at fire hydrants, any solids that may have contaminated the system. Then testing could begin, at 14 preselected locations. By Wednesday lab results showed adequate levels of sanitizing chemicals and no unwelcome bacteria.

Given the high volume of water in the Cape Fear basin, Ham said leaders of his system are not concerned that they’ll pull drinking water supplies from the Cape Fear River contaminated by agricultural or other wastes. If that sort of trouble does strike, the water can draw from Glenville Lake, its second water source.

Lethal floods

As of Thursday afternoon, the state Department of Public Safety said 22 people in North Carolina had died due to Hurricane Matthew. In advice about how to keep safe where flooding strikes, departmental leaders recommend people not drink well water from land that flooded until it’s deemed safe.

A fuel station in Lumberton inundated by rainwater deposited by Matthew. Many substances get into flood waters: soil, human and animal waste, chemicals and fuel create a toxic mix in floodwaters. Now that dozens of water treatment plants have been exposed to contaminants, it could take weeks for water in some Down East communities to be drinkable. Jocelyn Augustino/FEMA

In Lumberton, water supply may not be restored for weeks, a situation that the local hospital, Southeastern Regional, and individuals have been scrambling to cope with for days. On Thursday, volunteers were still carrying bottled water to people trapped in neighborhoods cut off by high water, said Linda Oxendine, Lumberton’s director of public services.

But Armstrong, Lumberton’s public works director, has a plan to move things as quickly as possible. With help from the U.S. Army Corps of Engineers and Federal Emergency Management Agency (FEMA), the city intends to use more than a dozen rented and otherwise procured pumps to clear flood water from the plant. That may take seven to 10 days.

Armstrong said he is not confident the intake that normally draws water from the Lumber River into the system will be functional. So his team will instead draw water from wells they usually use to dilute the river water.

A new generator should be running by the time it’s needed. But equipment repairs could take more time. If so, staff can always add sanitizing chemicals to the water by hand.

“We’ve got two things going for us. Most of our chemicals are okay and vendors are bringing more. And the well water we intend to use is easier to treat. It doesn’t have as much organics in it,” he said.

As sections of the water system come online, the Lumberton water system staff will start shipping water to homes and businesses, with a boil-water advisory intact. Then they’ll follow the same flush and test steps Fayetteville took to ensure clear and safe drinking water.

In two to four days, Armstrong said, with audible hope, the operation may approach “some semblance of normalcy.”

In the wake of the storm, many folks who have lost food will be eligible for temporary benefits. County officials will start taking applications  on Saturday.

By Rose Hoban

Residents of areas affected by Hurricane Matthew will be eligible for emergency food benefits through the U.S. Department of Agriculture Disaster Food and Nutrition Services Program, state officials announced Friday afternoon.

Supplemental Nutrition Assistance Program (SNAP ) logo

State officials held a late afternoon phone conference to detail the emergency program, which will provide people in 18 counties who are currently not receiving benefits Supplemental Nutritional Assistance Program (also known as food stamps) with a way to get food.

“Folks who have been impacted by flooding, lost food, lost their home, significant loss of jobs, or other impacts are eligible and can apply for assistance with the disaster application process,” said Wayne Black, director for social services and county operations for the state Department of Health and Human Services.

People who simply lost all their food because power to their homes was out for more than 8 hours are eligible, along with the people who have had more significant losses of property.

The application period is short – only from Saturday through Wednesday – so people will need to act fast.

“There’s another part of this… current recipients of Food and Nutrition Services will receive the maximum benefit, based on their household side… automatically through our NC FAST system a supplement,” Black said. He emphasized that those folks do not have to come in to apply for extra benefits, but the benefit will be applied directly to their Electronic Benefits Transfer cards.

To be determine eligibility, applicants for the disaster benefits will need to provide:

• Identification:  Photo ID or any other document that verifies your identity
• Residency (if possible)
• Utility bills, tax bills, or insurance policies, or a collateral (friend, employer, pastor, etc.);
• Social Security Number and date of birth for each household member (do not need Social Security Cards, just the number);
• Amount of take home pay for each household member

“With the D-SNAP program, many of the normal qualifications will be waived by the USDA,” said David Locklear, the chief of economic services for the state Division of Social Services. “Therefore, we will be accepting the client’s statement for other verification, other than identification.”

Locations for receiving applications will only be open for a few days, and they can get help for a one-month certification. (see table below)

“Individuals who wish to be considered for ongoing eligibility would have to return to their social services agency to apply for the regular food and nutrition services program,” Locklear said.

After Hurricanes Floyd, Fran and Irene, people in affected counties were eligible for similar benefits. Wayne said about 98,000 people received the disaster food relief after Floyd in 1999.

In addition to caring for students physically and emotionally, officials and students from the Robeson County campus reached out to the surrounding community after Matthew’s floods.

By Thomas Goldsmith

Hurricane Matthew dumped more than a foot of water and a load of problems on the University of North Carolina at Pembroke on Saturday, Oct. 8.

The mighty storm spared the college some of the damage visited up on nearby Lumberton, where the flooding Lumber River brought about widespread destruction and several deaths.

UNCP put up EMS workers from several North Carolina counties in its gym, where they slept in shifts. Photo credit: Thomas Goldsmith

No one died at UNCP, but the storm brought two to four feet of flooding. Most students left campus, reducing the student body of 6,300 to about 800 on the day the storm arrived, then to about two dozen. While looking after the physical and mental health of students, campus leaders and the facility itself also served as a key resource and as lodging for emergency personnel from across the state. Students and staff who returned to campus have continued to help other hard-hit communities in Robeson County.

Interviews with students, faculty, administrators, emergency workers and local residents showed that the college benefited from comprehensive emergency response planning and crafted aid for the nearby community as well as ensuring student and staff safety.

Here’s how the story unfolded:

Monday, Oct. 3: Hurricane Matthew heads for Cuba and UNCP officials take serious notice.

On that same day, Randy Faircloth, an Iraq veteran and Connecticut transplant, starts work at a Lumberton upholstery factory after other jobs don’t work out. He, wife Mary and daughter Kara, 9, live in a mobile home with their five dogs. They will be among more than 1,000 Lumberton residents displaced by Matthew who receive help from UNCP staff and students.

Wednesday-Thursday, Oct. 5-6: Travis Bryant, associate vice chancellor for campus safety and emergency operations, and other officials keep watch on Matthew, hoping that it will track far enough east to miss UNCP. Bryant gets out his 80-page disaster plan and the cheat sheets for specific tasks.

“It was coming up on the weekend and we were talking to students about emergency planning,” Bryant said. Administrators urge students to go home for the weekend. Most leave.

Dr. Robin Cummings, UNCP chancellor, holds regular meetings with his cabinet and leadership. Initially, he prepares to send help to UNC-Wilmington, based on projections of Matthew’s path.

Saturday, Oct. 8: The university is inundated by 12.5 inches of rain ending just before 6 p.m.

“Matthew sort of changed its mind,” Cummings said. “Suddenly we’ve got three to four
feet of water on campus.”

Randy and Mary Faircloth are Lumberton residents who were evacuated after Hurricane Matthew damaged their mobile home on Oct. 8. On Oct. 21 they prepared to leave a shelter at Purnell Swett High School in Pembroke, where UNC-Pembroke students and staff worked among the volunteer staff. Photo credit: Thomas Goldsmith

Saturday morning, Oct. 8: As water starts to pour into their mobile home, Mary and Kara Faircloth shelter on higher ground at a friend’s nearby brick home. Kara, who is on the autism spectrum, is severely shaken by the storm. Randy stays to look after the family’s animals.

Around 1 p.m.: UNCP campus loses power with 800 students on campus. The 16-member police department fires up its natural-gas generator.

“The rain and the wind were frightening,” Bryant said. “Without lights, it’s difficult to respond to an emergency. When you lose power, you lose communications.”

Staff members for Sodexo, the generator-equipped campus food vendor, prepare food for remaining students, serving 2,300 hot meals and 900 box meals using generator power. Many staff members have flooding or other problems at home, but most remain on the job. Staff delivered food to students who worried about leaving their dorms.

“These people are in absolutely desperate situations but they are helping each other,” Bryant said.

Students are told not to drink the water on campus. Some use the solar panels in front of the library to charge their phones, but heavy cell traffic prevents calls from connecting .

Sunday, Oct. 9: UNCP’s Counseling and Psychological Services, or CAPS team, begin a week of on-call duty to help students. The employee assistance program offers help to those who need either mental health aid or help with flood damage, financial issues, etc.

UNCP senior Whitney Jackson, of Farmville, worked at the evacuee shelter at Purnell Swett High School in Pembroke. Photo credit: Thomas Goldsmith

“Our first goal was to take care of our 800 students on campus,” Cummings said. “Over the week we whittled that down to 20 to 25. We did things like posting a guard in every dorm.”

Sunday evening, Oct. 9: A student’s family calls from Lumberton, asking directions to UNCP so they could pick up their daughter. Instead of trying to steer them down treacherous roads in the dark, Bryant takes a pickup truck and delivers the daughter and two friends at about 7:30 p.m.

Sunday afternoon, Oct. 9: Mary and Kara are evacuated from flooded Lumberton, with only the clothes on their backs.

Monday, Oct. 10: Crystal Moore, a nurse practitioner in UNCP student health services, checks the campus along with other staff to ensure student safety.

With his trailer in ruins, Randy Faircloth catches a bus picking up storm evacuees. It happens to take him to Robeson County’s Purnell Swett High School on Deep Branch Road, where he is reunited with Mary and Kara. The dogs are housed free at at the county animal shelter in St. Pauls, except for Stewart, a Jack Russell who ran off in the storm. During Hurricane Katrina, emergency officials across the country learned that many people will refuse to leave home without their pets.

Whitney Jackson, center fielder on the UNCP Braves softball team, serves flood evacuees as one of what she called an “outrageous” number of students working at the community shelter set up at Purnell Swett.

NC Emergency Management Director, Mike Sprayberry, with UNCP Robin Cummings at the shelter at Purnell Swett H.S. Photo courtesy: UNCP Facebook page

“The chancellor named Monday a service day. The community came together here and absolutely outdid everything,” Jackson said. “There were people who needed 24-hour care and got it. We didn’t know how bad it was going to be.”

Both gyms at Purnell Swett are full of people and additional shelters are set up at Southeast Robeson High School and other locations.

As disaster aid from across the state arrives Monday in hard-hit areas, those workers need places to stay.

“We had all these National Guard members and first responders asking was there someplace they could sleep,” Cummings said. ”We said, ‘Oh, yeah, we have a gym that’s 9,000 square feet.’”

Also on Monday, staff drive the food produced for the expected 200 emergency workers to Lumberton when the workers’ large vehicles are hampered by flooded roads.

Robin Roberts of Johnston County emergency services spent more than a week living in a UNCP gym as she aided Hurricane Matthew evacuees. Photo credit: Thomas Goldsmith

Tuesday-Wednesday, Oct. 10-11: Power is restored to campus and cleanup begins.
Emergency workers, including swift water rescue teams with specially designed boats, work out of UNCP in Lumberton and other flooded areas. Moore and other campus health staff work in shelters as few students remain on campus.

October 12: Gov. Pat McCrory visits UNCP with state Emergency Management Director Mike Sprayberry to assess situation as part of his tour of areas hit by Matthew.

Thursday-Friday, Oct. 12-13: Previously planned fall break allows time for campus to recover.

Thursday, Oct. 12: Mary Faircloth returns to her old neighborhood and locates Stewart, their missing Jack Russell terrier.

Friday, Oct. 13: EMS worker Robin Roberts from Johnston County arrives on campus with other EMS workers.

Nearby communities including Lumberton and Fair Bluff continue to experience devastation. UNCP provides overnight lodging for emergency workers from Buncombe, Franklin, Wake, Durham, Johnston and other counties.

UNCP starts a hurricane relief fund to help students who lost computers, clothes or other belongings when their residences flooded.

Monday, Oct. 16: Campus reopens for some staff members.

Tuesday, Oct. 17: Classes resume and UNCP offers the community a free showing of the acrobatic “Shanghai Nights” as relief from the stress and tragedy of the preceding nine days. The performance is full.

The Faircloths, among 300 people still in shelters, make plans to move to Fort Bragg, where Randy’s veteran status affords them a motel room. They accumulate donated possessions, but Mary contracts a gastrointestinal illness that she attributes to contaminated flood water.

Randy and Mary Faircloth are Lumberton residents who were evacuated after Hurricane Matthew damaged their mobile home on Oct. 8. On Oct. 21 they gathered donated belongings as they prepared to leave a shelter at Purnell Swett High School in Pembroke, where UNC-Pembroke students and staff worked among the volunteer staff. Photo credit: Thomas Goldsmith

Thursday, Oct. 20: Robin Roberts and other emergency workers are still living in the UNCP gym, responding to the ongoing need for help in flooded areas.

“Everybody has been extremely grateful,” Roberts says, as workers on another shift sleep nearby. “Even the students walk by and say thanks.”

Intact, but in low spirits, the Faircloths leave Purnell Swett for Fort Bragg in Randy’s aged Pontiac. They’ll have the dogs to pick up and a temporary home as they meet with FEMA about a new place to live.

Friday-Saturday, Oct. 21-22: In another stress reliever, UNCP opens up a Friday performance by the Prince tribute band the Purple Xperience free to students and community members. Homecoming weekend is celebrated as the Braves face the Catawba University Indians in football.

Health outcomes in the far southeastern part of North Carolina are some of the worst in the state. But some folks are making a concerted effort to turn those numbers around.

By Thomas Goldsmith

When pediatrician Laura Gerald returned to her hometown of Lumberton as head of the Kate B. Reynolds Charitable Trust, she told the welcoming crowd that she had plenty to discuss with them.

A showing the decay of downtown Parkton, North Carolina. This town, like many others in Eastern North Carolina, is a shadow of its former bustling self. Reasons for the decline include the loss of textile mill jobs and dramatic downturn in tobacco farming. Photo courtesy: Gerry Dincher, Wikimedia Creative Commons

“Normally, I’d only be up here for about 10 minutes, but I’m home, so you might as well settle in,” a smiling Gerald told a gathering at Southeastern Regional Medical Center in September.

But the Harvard- and Johns Hopkins-educated physician left no doubt that she was well acquainted with the health challenges faced by residents in Robeson County in Southeastern North Carolina.

A person born in Robeson County has a life expectancy of about 73 years. About a hundred miles away in Wake County the comparable life expectancy is 81 years, she told the crowd, in numbers referenced in a Robert Wood Johnson Foundation report.

“Why should something as simple as the Zip code you were born in give you seven more years of life?” Gerald asked.

One in three

Robeson County, with a population of more than 133,000, lies in the state’s scenic Sandhills region. Multiple factory closings in recent decades has lead to an unemployment rate that’s stuck at nearly 7 percent, down from years of recession-driven double digit rates.

And one in three Robeson County residents lives in poverty.

Robeson County. Image courtesy U.S. Census

“A lot of rural North Carolina issues relate to poverty, like obesity and this recent opioid epidemic,” said Dr. Pearly Graham-Hoskins, a friend of Gerald’s and hospitalist and medical director at Cape Fear Valley – Bladen County Hospital. “The thing people forget is that it’s an economic issue. People are selling drugs and they’re trying the drugs.”

Graham-Hoskins was in Lumberton, the county seat, to attend Gerald’s first hometown appearance since she was installed as president of the Kate B. Reynolds Charitable Trust. The Winston-Salem-based foundation is among the nonprofit, academic, public and private entities working to address health problems in the county.

(The Kate B. Reynolds Trust has also granted NC Health News with funds to focus on rural health issues through a donor-advised fund at the Winston-Salem Foundation.)

Public health officials say the county’s troubling health statistics arise from a number of factors, some of the most persistent linked to ingrained cultural issues as well as the county’s lack of economic dynamism. Young people in Robeson experience a death rate 60 percent higher than the state average. And the overall homicide rate is more than triple the state average.

Dr. Joseph Bell, a Robeson County native, returned to Pembroke to found the Pembroke Pediatrics clinic after getting his medical degree from UNC-Chapel Hill. Photograph by Thomas Goldsmith.

‘There are historical divisions’

One key to the rate of violent crime could be a statistic that also makes Robeson distinctive: A diverse population that’s 39.9 percent Native American, 32.2 percent white, 24.4 percent African-American and 8.3 percent Hispanic, according to 2015 census numbers.

“There are historical divisions and tensions between different groups on the ethnic side,” Gerald said.

Dr. Joseph Bell is a Lumbee Indian and Robeson County native who earned first a pharmacy degree, then a medical degree from the University of North Carolina at Chapel Hill before founding Pembroke Pediatrics in Pembroke. He agreed with Gerald’s assessment of tensions that can lead to stress and violence between ethnic groups.

“The old historic tension and racial prejudice — anyone would be naive to think that that had totally gone away,” Bell said.

A mix of resources

Lumberton is home to the 452-bed Southeastern Regional Medical Center, a nonprofit facility which treats 16,000 inpatients and 68,000 emergency patients from across the region annually. The hospital and its parent organization, Southeastern Health, held the homecoming for Gerald.

“We have great hospitals and great doctors,” state Sen. Jane Smith, who represents Robeson and Columbus counties in the General Assembly, said at the event. “The outcomes are mostly attributable to the poverty rate.”

Many Robeson County residents wind up in a hospital emergency department for care because they can’t afford regular medical care, Smith said. She also expressed frustration that the Republican legislature refused to expand Medicaid, as is allowed for under the Affordable Care Act.

Smith, a Democrat, ran for reelection this month, stressing the need for a strengthened education system, job creation through economic development organizations, promoting business and agriculture, and ensuring that rural areas get their fair share of resources.

She lost to Republican lawyer and military veteran Danny Britt, who said Smith had been ineffective in Raleigh.

“We have the opportunity to market our positives, our location and resources, to bring jobs and wealth back to Robeson and Columbus Counties,” Britt told the Robesonian.

Obesity, asthma, vehicle crashes plague county

One of Robeson County’s problems, both economic and health-related, is the presence of food deserts, regions where fresh produce and other items are absent from stores or difficult to obtain.

Closed businesses in the Sandhills result unemployment, which can lead to health problems. Robeson County ranks last in the state in several health indicators. Photograph by Thomas Goldsmith.

“One of the biggest problems is the access to healthy food,” said Tim Bell, CEO of Children’s Health of Carolina. “We have obesity in both children and adults.”

Other conditions, such as a rate of inpatient hospitalization for asthma among children 14 and younger that’s twice the state average, could be linked to longstanding unhealthy habits.

“There’s a high percentage of asthmatics,” Bell said. “We know there’s a fair amount of smokers.”

And high rates of substance abuse correlate to notable deaths from unintentional motor-vehicle deaths — 35 per 100,000 compared to a statewide average of less than 20 per 100,000.

Solutions to some problems come from concentrated efforts such as the Robeson-Columbus counties Nurse-Family Partnership. The partnership’s registered nurses work with first-time mothers until their children are two years old, boosting positive outcomes and improved statistics in key areas such as immunization and breastfeeding rates.

Five-year effort brings results

Some problems are so intractable as to require even broader interdisciplinary efforts, such as the North Carolina Academic Center for Excellence in Youth Violence Prevention, known as NC-ACE. The initiative won nearly $6.5 million in federal funding to allow UNC researchers, led by School of Social Work professor Paul Smokowski, to work toward community support and solutions for preventing and reducing youth violence in Robeson County.

The UNC effort is nearing an end in December, when a full report of its work will be released. But results already in show impressive outcomes from its Teen Court, Positive Option and Parenting Wisely programs, Smokowski said in a phone interview Friday from his new post at the University of Kansas.

Teen Court juror Cierra Dial, 17, says she learned to avoid trouble through participating in the Teen Court process. Photo credit: Hyun Namkoong

“Very briefly, the difference with Teen Court is that it reconnects them largely to community service,” he said. “Instead of a sentence we call it a sanction. They have to do community service, they have to make reparations from whatever the damage is.”

Youth who have gone through Teen Court in Robeson have a recidivism rate of less than half that of those who are handled by the juvenile justice system, he said. Positive Option works with middle-school students to create a more positive school climate by decreasing behaviors like bullying and disrespect. Parenting Wisely helps mothers and fathers manage conflict with their teenage children.

“Parent-child conflict is a risk factor for delinquent behavior, for substance abuse, for violence and aggression, and for teenage promiscuity,” Smokowski said. “When you can decrease that conflict between parents and children, it keeps the adolescents closer to the family. There’s less aggressive behavior and less violence.”

Gerald said no one person or organization can solve Robeson County’s problems alone.

“It’s going to take public health, colleges, community colleges, the faith community and the business community. It takes all of those sectors working together,” she said. “We want to secure a future of hope and opportunity for our children.”