Heppner—From the hill on the east side of Heppner, Pioneer Memorial Hospital has a birds-eye view of the Morrow County seat.

Molly Rhea, director of nursing services, looks out of the glassless window frame on the hospital’s south side. From here, you can see most of the town and most of the homes for its 1,400 residents.

Right down there, she says, a few blocks from the courthouse, is the house where she grew up. On that hill over there, a little west and north of downtown, is the high school she attended before going away to nursing school.

You can’t see it from this window, but just south of town and slightly east is Willow Creek Dam, the world’s first roller-compacted concrete dam.

And just outside the window of Molly’s office on the floor below, a family of quail gathers on the lawn for lunch.

Molly Rhea points out Heppner's landmarks from the new nursing wing of Pioneer Memorial Hospital. Photos by Jerry Rhodes

These windows will give a nice view for the residents and staff when the new seven-bed long-term nursing wing is finished.

Once home to a 32-bed nursing home, this wing of the hospital closed in 2003 after years of losses. The Morrow County Health District, which owns and operates the hospital, is rebuilding the wing with eight beds for the nursing home that can do double duty as licensed hospital beds. The designation will bring the district a higher rate of compensation.

“We won’t break even, but we’ll be within $40,000,” says Hospital Administrator Victor Vander Does. “Before we were anywhere from $200,000 to $400,000 of losses every year.”

The new nursing wing is a bright spot and a source of pride for Victor, Molly and the rest of the staff (30-some at the hospital, many with shared duties with the Health District, which employs 70 full time). But the wing also demonstrates the challenges of operating a hospital in a town small enough that you can point out all the landmarks from a single window.

Small town pluses…

In many ways, there are advantages to living in a small town. A five-minute commute all the way across town certainly is worthy of envy. And it’s nice to be able to greet every person on the street by name.

“I think we have to be more polite, because we see these people all the time,” says Molly, a lifelong Heppner resident who gained her big-city experience while studying nursing at Portland’s Good Samaritan Hospital.

And the old axiom about being considered a newcomer for the first 30 or 40 years of residency doesn’t quite hold up like it used to, she says.

“We’re quick to welcome you because we need more people,” Molly says. Having new people means some of the burdens of community can be shared.

Take Molly and her husband. Steve is a descendent of Oregon Trail pioneers and an insurance agent. He’s been on the city budget committee, is Heppner’s volunteer assistant fire chief and for weeks this summer was in California working as a firefighter. Molly is the Lion’s Club secretary, is active at the Methodist Church, used to be a coach and still yells encouragement from the sideline.

…and small hospital challenges

At the hospital, everyone pulls double, triple, even quadruple duty.

The administrator, Victor Vander Does, sometimes works as a volunteer ambulance driver (usually on St. Patrick’s Day, he says). Molly, the director of nursing services, also heads up home health and hospice, and is a backup nurse in the emergency room.

“Some days, when you get busy, all your plans for big projects just have to be pushed aside,” she says.

In lieu of a security staff, nurses keep an eye on the monitor that acts as a security system.

That’s sometimes an advantage. Just from that single glimpse on the monitor, many times the nurse will recognize who’s coming in for urgent care, know what crop they were bringing in that day and what pulled muscle is likely to be the diagnosis.

More often, the small town presents real challenges for services, structure and staff, Victor says. So the hospital makes adjustments and makes do.

Pioneer Memorial no longer does surgeries or handles childbirth. There weren’t nearly enough surgeries and births to keep obstetricians, surgeons and anesthesiologists busy, so they had to drive in from Hermiston or Pendleton. Now surgical patients and mothers in labor make that hour-long trip in the opposite direction. But in the space left vacant by these services, the hospital now houses administration as well as a CT scanner and digital X-ray. That means fewer trips out of town for trauma patients to follow up on suspicious neck injuries or possible skull fractures. Just like reopening the long-term nursing wing means families won’t have to travel out of town for visits.

Size definitely makes a difference when it comes to finding staff, Molly says.

“I try to play the small town up as a good thing, but finding qualified people is hard,” she says.

Many nurses, for example, enjoy the professional challenge of handling additional duties that large hospitals have specialists doing. But most don’t want to have janitorial duties also, or to live an hour from the nearest movie theater and other cultural niceties.

A lot of times, the best place to find people is right at home, Molly says. There are other home-town kids like her who’ve gone off to school but want to come home. And there are relatives of people already on staff.

“We do OK with attracting providers,” Victor says. Two new doctors came on board just in the last year: Betsy Anderson, MD, came from Corvallis, and Russell Nichols, MD, came from John Day. Both are primary care and emergency room physicians.

But many physicians spend only a few years, having signed on to a federal program that places physicians in rural communities in exchange for reduced debt for medical school. Once their obligation is complete, many will move on.

Quality improvement in small town practice

Medical care in the United States is under tremendous pressure to reduce costs and improve quality. That’s where some of the greatest challenges lie for rural hospitals.

“My frustration is that we have so many requirements and there are so few of us,” Molly says.

It would be nice if there were enough staff to have someone who could do infection control as their primary duty.

It would be nice to have electronic medical records so that medical reconciliation wouldn’t be such a difficult issue.

It would be nice if the director of nursing services/home health and hospice director didn’t also have to be the quality improvement department.

But then it wouldn’t be a small hospital.

How rural hospitals adapt

An example of how rural hospitals have learned to make the best use of resources and time is the annual Oregon Rural Health Conference, which is Sept. 25-27 in Bend this year. The conference brings together the Oregon Rural Health Association, Oregon Area Health Education Centers, Oregon Rural Healthcare Quality Network (ORH), Oregon Rural Practice-based Research Network and the Oregon Office of Rural Health. It’s the largest gathering of participants involved with rural health in the state.

By bringing all the programs and organizations together at the same time, the conference cuts down on travel costs. Just another example of how rural hospitals have learned to contain costs, Scott Ekblad, ORH director.

For a small-town hospital to work, it must have a staff that will do more than what’s written in just one job description.

Take Carl Lauritsen, maintenance supervisor at Pioneer Memorial Hospital in Heppner.

“Maintenance” means he’s also overseeing the remodeling of the long-term nursing wing, as well as the expansion at the adjacent Pioneer Memorial Clinic.

He’s also a paramedic, responsible for saving lives when the ambulance is called. All the maintenance crew members, in fact, are EMTs.

There’s more. Here’s what was written back in 1999 when the Oregon Department of Human Services awarded Carl its Distinguished Service Medal:

“Carl is often THE paramedic in southern Morrow County. He effectively coordinates First Responder services on his own, and in his spare moments, wears the hats of the County EMS Coordinator, the ATAB 9 Representative, Hospital Trauma Registrar, EMT Basic and Intermediate Course Director, and Pioneer Memorial Hospital’s cheerleader.”

Oh yeah. The landscape photos that grace the hospital’s walls are his, too.

Pioneer Memorial Hospital in Heppner may be the smallest Oregon hospital, but it’s not the only one facing the challenge of 21st century medicine in a rural community. Most of Oregon, in fact, is considered rural (see map)

And across the country there are hundreds of hospitals in the same situation. Congress has recognized the special challenges faced by these hospitals and the importance of keeping them open. Through the Medicare Rural Hospital Flexibility Program, a provision of the 1997 Medicare Modernization Act, hospitals with 25 or fewer licensed beds can be designated Critical Access Hospitals (CAH). These hospitals receive enhanced reimbursement for Medicare and Medicaid patients.

To qualify, hospitals must meet certain conditions, such as reporting and quality improvement.

The Oregon Office of Rural Health (ORH), a statewide organization headquartered at Oregon Health & Science University, was established in 1979 to provide assistance to rural providers. That includes helping rural hospitals in the state fulfill their requirements under the CAH designation.

“For example, one of the CAH requirements is that hospitals must send out a random sample of charts for outside peer review,” says Scott Ekblad, ORH director.

For small hospitals, the cost was prohibitive, ranging up to $1,000 per chart.

“And if you sent a chart to an urban physician, you wouldn’t be getting a true peer review,” he says. Instead hospitals would get reviews that were totally unrealistic in the rural setting, for example, recommending that a specialist should have been called in for a case when the nearest physician with that qualification was hundreds of miles away.

So the Office of Rural Health worked with the members of the Oregon Rural Health Quality Network to set up a system of peer review using physicians within the network. ORH provided the training and distributes the charts—with identifying information redacted—to reviewers.

“We only charge the cost of postage,” he says.

The Oregon Office of Rural Health, through the Rural Hospital Flexibility Program, provides much of the support for the Oregon Rural Healthcare Quality Network. The network is now a separate private, non-profit organization and survives on federal grants and member hospital dues. There are active participants from 20 hospitals around the state.

“Quality improvement programs often must be retrofitted to work in a small, rural setting,” Scott says. “If they want to embark on a quality improvement initiative, they can get advice from other people in the network or contracted experts. The consultants will come in and share their expertise and best practices from around the country.”

The office also operates a program to help rural providers recruit and retain health care professionals. Rural sites can send their practice opportunity listings to the office’s Recruitment Services Coordinator, who will then post them on a national web site dedicated to rural health care. The office then refers candidates to the practice sites, and works with both parties to ensure an efficient and effective recruitment process.

The Oregon Rural Health Services Loan Repayment Program will repay qualifying loans for practitioners who agree to serve a minimum number of years in designated rural areas.

Physicians, dentists and pharmacists can receive a payment each year equal to 20 percent of their loans if they serve at least three years. (If they leave before their obligation is complete, they must pay a penalty equal to 150 percent of the benefits they’ve received.)

Nurse practitioners and physician assistants can receive up to 25 percent of their loans each year and have a minimum obligation of two years.