Working together: Urban, smaller health centers build partnerships to adapt to changing medical landscape
DEVILS LAKE, N.D.—As bitter 70-mph winds whipped up an early season snow squall, Darrell Nilep sat comfortably in a clinic examining room in his jeans and a black sweatshirt.
Diagnosed in 1995 with kidney disease, the 67-year-old Devils Lake man already had undergone seven other major surgeries before receiving a kidney transplant in October 2016. Now just past the first anniversary of that eighth and final life-changing surgery, Nilep said he was feeling well and looking forward to his first face-to-face appointment with kidney specialist Dr. Adetola Haastrup. But then the storm hit.
The nephrologist based at Altru Health System in Grand Forks would not be able to make the 90-mile trip to see her patients in Devils Lake that day. What now?
The answer would be some shuffling and a quick shift to Plan B.
Though Nilep would not be able to meet Haastrup in person, his appointment would go on as scheduled. He would see the doctor face to face, but it would be via live video.
"You are doing well. Keep it up," Haastrup told Nilep from a large computer screen. Altru outreach nurse Lisa Elverud also was in the room to help operate the camera, take vitals and do all the other things a nurse ordinarily would do during a more traditional appointment.
"This is a testament to the program," Haastrup said, referring to Altru's regional health care and telemedicine programs.
Far and wide
Nilep is just one of about a quarter-million people across 46 communities and 17 counties in north-central North Dakota and northwest Minnesota to be served by the outreach programs.
The innovative telemedicine program that originated with kidney care a decade ago now covers more than 30 different medical specialties. Treating everything from oncology to orthopedics, weight management to wound care, up to 45 Altru specialists regularly travel to see patients at their hometown health centers.
Urban and smaller, more rural care centers have built multiple partnerships to adapt to a changing medical landscape. Along with telemedicine and regional outreach, there also has been an evolution in electronic recordkeeping.
"We span over 400 miles east to west and 120 miles north to south, so it really is a huge swath," said Jennifer Nuelle-Dimoulas, director of Altru's regional clinic operations. "A lot of external forces are impacting our health care, and we're not immune or isolated from that.
"We see an aging population. We see worker shortages. ... Consumers are demanding more from our health care systems. They're savvy and tech-smart. So, it really challenges us to be at the forefront of technology."
Outreach and the ready connection to the right care and technology can be the difference between life and death for patients such as Nilep.
"To me, it's as good as you can get," he said. "The fact there is a dialysis center here is amazing. They're a lifeline. If you don't go to dialysis, most people die within a month. In the time I was on dialysis, 43 people died."
Dialysis is an artificial process that cleans the blood of toxins. The treatment is time-consuming, expensive and necessary. And at CHI St. Alexius Health Devils Lake and across the region it is high in demand.
Before his transplant, Nilep was dependent on full-time dialysis for about eight years. At first unable to fit into Devils Lake's crowded dialysis schedule, Nilep said almost half of his waking hours revolved around his disease.
Three days a week, he left home for Grand Forks with the sun in his eyes, spent up to five hours on dialysis, then returned home with the sun in his eyes. It was a grueling routine, so it came as great relief when he finally was able to get treatment closer to home through a partnership between CHI and Altru.
"The difference was hours, money, time and sense of well-being," Nilep said. "Here (at St. Alexius Devils Lake), I would go four, five hours in the morning and get done. The rest of the day was my own because of this satellite dialysis."
How it works
Marsha Waind is the manager of regional services and telemedicine at Altru. She said such partnerships are a win-win for patients as well as smaller communities.
"There's a host of data and information that flows back and forth," Waind said. "The specialists here make sure they get the tertiary care when they need it. Otherwise that care can stay local. Regional care keeps local dollars in these small towns, and it keeps a network going between the specialists and the primary care providers.
"It's very important that primary care providers feel supported in the rural towns. That's part of our goal to make sure we keep the small-town network of medical care alive."
Patients benefit with better access to the specialty care that may require more advanced and complex procedures. The outreach care cuts travel time and expenses, reduces time away from work, and increases the ability of family members to be involved.
"So say I'm going to have labs done in Park River and then send them here for review. Same thing with X-rays, EKGs and ECGs. The nursing home might get that X-ray taken so the 85-year-old grandma from Park River doesn't have to come all the way to Grand Forks for the 10-minute visit to hear 'Yes, you're healing well,' " Waind explained. "That's a big deal. Wound care is big. And again, it's a very coordinated care between the specialists here and that local care team."
Waind said a telemed visit is much the same as a regular visit and just as personal. Electronic stethoscopes can send live heart and lung sounds, and though separated by miles, tools allow doctors to peer into patients' ears and mouths. Lab work and other tests can be done remotely and efficiently.
"There isn't very much we can't do," Waind said.
Andrew Lankowicz, president of CHI St. Alexius Health Devils Lake, said the kidney dialysis unit is the perfect example of a partnership that works well.
His 25-bed, critical access hospital leases space to Altru for the six-chair dialysis unit. It runs two shifts six days a week, and there is a waiting list.
Formerly known as Mercy Hospital, the Devils Lake facility was once a longtime independent hospital with 110 beds. But like many hospitals nationwide, it's now under the umbrella of a larger network. Its parent CHI, or Catholic Health Initiatives, was named the nation's fifth-largest, not-for-profit, health care system in 2015.
Lankowicz described a sea change in the medical industry.
"The traditional model of medicine was hospitals were stand-alone. In our parents' generation, 20 to 40 years ago, most physicians were independent, and they applied for privileges at the hospitals," he said. "Now 90 percent or more of the physicians in North Dakota are employed by health systems."
Advancements in medicine required more complex equipment, more expertise to run it and more medical professionals at all levels. That, paired with a mountain of regulations governing how providers are reimbursed for services, created an industry that demanded as much business smarts as medical knowledge.
Lankowicz said his hospital has adapted by finding its own niche and building a conglomeration of partnerships. Another good example would be obstetrics, he said. Altru provides the doctors and prenatal care through its Devils Lake clinic while CHI provides the hospital-based care—the ultrasound, anesthesia, nursing, surgical techs, operating room and equipment.
CHI also leases land to Valley Medical Flight and partners with Minot's Trinity Hospital for eye surgeries and Grand Forks' Cancer Center of North Dakota for cancer infusions. It leases space for the VA Community-Based Outpatient Clinic and also connects with South Dakota's Avera Hospital for eEmergency services.
CHI has its own nuclear medicine program and a state-of-the-art CT scanner and MRI equipment, Lankowicz said. It provides many of the same high-tech tests its urban counterparts do. The only difference might be that some tests are read by off-site specialists.
"The more complex cases will go to the larger cities, but the ones that can be done locally will be done here," Lankowicz said. "We're never going to do open-heart surgery here. We'll never do kidney transplants. Those are done at tertiary medical facilities, but we'll definitely do colonoscopies, preventive wellness and minor surgery."
The urban care centers and smaller ones complement each other, he said.
"The reality is nobody can operate in a vacuum. We rely on each other," he said. "With that in mind, we're still competitors. We're operating in the same space, and there is some overlap of some services. That's a challenge we have to work through. We have a very good working relationship with Altru. We don't always agree, but we try to work through the issues."
Lankowicz said he's proud of his hospital's place in the community.
"Our quality of care is as good or better as any of the larger hospitals," he said. "When people get their care here, we're caring for each other. That's what makes us special. When you walk in the door, you're not a number. You're Uncle Mike."