Blog Post

Healthcare Upside/Down: Resilience in Rural Healthcare

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ECG’s radio show and podcast, Healthcare Upside Down, offers unfiltered perspectives on what’s working in US healthcare and what’s not. Hosted by ECG principal Dr. Nick van Terheyden, each episode features guest panelists who explore the upsides and downsides of healthcare in the US—and how to make the system work for everyone.

More than 800 rural hospitals are at immediate or high risk for closure, according to a report by the Center for Healthcare Quality and Payment Reform. That same report noted that almost every state has at least one rural hospital at risk of closure, and in one state, all rural hospitals are at risk of closing.

The impact on communities is significant. Residents should be able to conveniently and confidently access services such as primary care, dental care, behavioral health, emergency care, and public health services. When these are tens and sometimes hundreds of miles away, the local population suffers.

But there are repercussions beyond the availability of prompt medical care. The healthcare system is often a community’s biggest employer, so losing a system damages the local economy and diminishes the ability to attract new businesses or create an attractive living environment. These communities are already struggling with a disproportionate amount of mental health issues, substance abuse and chronic disease burdens, and higher mortality and morbidity.

That puts even more pressure on the broader healthcare system—which is already struggling—as these residents seek care in the surrounding areas; and to be clear, that is only an option for those who are able to travel to remote facilities. Emergency services become further strained as they transport patients longer distances, tying up these resources for extended periods of time.

Angela Ammons, CEO of Clinch Memorial Hospital (CMH) in southeastern Georgia, has seen this up close. Despite the challenges posed by geography and a host of economic drivers, she remains unbowed in her efforts to make rural healthcare more accessible and sustainable. “I think failure can be seen two ways,” she says. “As a true failure, and you feel defeated; or as a step closer to another success.”

A registered nurse who went on to change the fortunes of a 25-bed critical access hospital, Angela talks about resilience in rural healthcare on episode 17 of Healthcare Upside Down. Here are three takeaways from our conversation.

Defining success.

For the leader of a rural hospital that’s lurched from the brink of insolvency to generating millions of dollars in revenue over the course of a few years, the definition of success is a moving target. When Angela became CEO of CMH in 2017, the hospital had an average daily census of 1.8. She needed to fill beds and retain her staff.

“How I defined success in the first year I was CEO is much different than how I define it now,” she says. “That first year, it was defined as keeping the doors open for another year, making payroll consistently.”

Unsurprisingly, the pandemic created new challenges for the hospital, and Angela once again finds herself recalibrating her measures for success. “Now success for us is just surviving another wave of COVID,” she says. “The novel virus keeps coming in waves, and we have to navigate the reimbursement, utilize the resources that are given to us, and stay open and keep 150-plus employees.”

Swing beds as a revenue driver.

It was while trying to ensure the hospital’s survival in the short term that Angela implemented a program that would later fortify CMH for its battle with COVID-19. Desperate to fill empty beds, Angela began accepting intubated patients from larger hospitals in Georgia and from out of state. It required a substantial up-front investment in ventilators and staff, but the strategy enabled CMH to bill the federal government for care of the patients.

Given CMH’s designation as a critical access hospital, Angela was also able to “swing” her beds—caring for patients who no longer require ED services but are not yet ready to transition to a skilled nursing facility. “Within nine months of implementing this new program, we saw over $5.2 million in Medicare revenue, which afforded us to hire additional staff, buy capital equipment, and continue” operations, Angela explains.


CMH’s growing experience with ventilators became invaluable as COVID-19 spread. “Little did we know that that preparation would set us up for success in battling a virus that attacks the respiratory system and places people on ventilators,” Angela says.

What it means to be resilient.

CMH’s turnaround is a product of innovation, determination, and above all, resilience. But for Angela, it’s necessitated a sense of personal resilience as well. “It’s been hard to win the community over,” she acknowledges. She’s had to make difficult decisions about the direction of the hospital and the composition of the staff. She endures public criticism and periodic calls for her ouster. Transforming the culture of any organization can be a political and emotional minefield.

But there’s been praise as well. The success of CMH’s ventilator program boosted the hospital’s visibility, garnering recognition from politicians and the press, which has helped Angela secure grants and zero-interest loans that have kept the hospital afloat. Angela’s personal profile has been on the rise as well, as she’s been interviewed by regional and national media outlets.

Some might welcome the attention, but the self-described “huge introvert” has had to make some adjustments. “My favorite thing to do is just go home, read a book, and be with my dog. That’s my way to reenergize,” Angela says. “I really had to get out of that comfort zone. I had to do it for the hospital, I had to get our name out there. When I picked up the phone and asked for help, I wanted people to know who Clinch Memorial Hospital was, so that work on the front end has continued to set us up for success.”

How can healthcare leaders develop resilience?

Angela talks more about what it takes for rural hospitals
to thrive.

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