By Debra Moore
The OB program. A skilled nursing facility. A new hospital. Employee housing.
Any one of those endeavors would tax a rural healthcare district, but Plumas District Hospital is facing them all at once. During the June 9 board of directors meeting, hospital staff and the directors discussed the four issues that although separate are also intertwined.
Obstetric services are currently on diversion at Plumas District Hospital. Women who anticipated delivering their babies at PDH can still receive prenatal care there, but must go elsewhere for the actual deliveries due to a nursing shortage at the hospital. Doctors and staff hope this will be a temporary situation while a long-term solution is worked out.
Dr. Erin Barnes has been at PDH for 12 years, with 10 years as the medical director for the OB program. She said she could speak for the physicians regarding their unhappiness that the program is on diversion, “but we want to develop a program that is sustainable.”
She also addressed the nursing situation — OB nurses want two OB-trained nurses available at each delivery. At times, there was only one. “I want to clarify for the board and the public … at no time did I ever feel that we were practicing obstetrics unsafely at PDH. The guidelines state that there should be two nurses at each delivery.” She went on to say that the guidelines didn’t specify what type of nurse was required.
Dr. Ross Morgan also addressed the issue and said that the hospital was able to attract quality doctors because obstetrics was offered. “Doctors like Dr. Barnes wouldn’t be here,” he said. “I’m hopeful that we can get something sustainable. I agree with her (Dr. Barnes) that we have had adequate and safe staffing. My support remains with keeping the obstetrical program alive.”
Dr. Jeff Kepple told those attending the meeting that he hadn’t practiced obstetrics at the hospital for six years and realized that circumstances might have changed. He cited higher risk deliveries as one such change, as well as staffing shortages. Then he went on to address why he thinks the OB program is critical.
He started with a basic tenet of providing OB services — “adverse events and threats to pregnancy and delivery are there.” Then he asked the question: “Are we going to be there to minimize the events and adverse outcomes?”
“OB is awfully simple or simply awful; there is no way to predict,” he said. “Some of my worst cases were absolutely unpredictable. The real question is will we be there, and will we be able to provide the best care that we can?”
And it’s not just expectant mothers who will be impacted. Kepple said that as OB programs are dropped, it affects other programs. The questions are then asked: Why do we have surgery? Why do we have two surgeons? Why do we have an anesthesiologist?
“Thriving communities in rural areas have OB programs,” he said. “Otherwise they become a retirement community or you can’t recruit young families.”
Board member Guy McNett asked more questions about the guidelines as they pertained to two nurses. Dr. Barnes responded that across the nation having two labor and delivery nurses is typical. The traveler nurses who come to PDH expect that. She said, “If our nurses are feeling unsafe; we don’t want to minimize that.” But she reminded the meeting attendees, “Year after year we won safety awards for our program.”
Dr. Paige Lewis also addressed the nursing situation. “There are so many times when I need extra hands,” Lewis said. “The ER doctor and the ER nurses show up. The nurse is never alone.” She said that when she first moved to the area seven years ago she came from an area with major OB programs and at first she was concerned, but she said there is always help available.
“We have a neonatologist from UC Davis that is always available,” Dr. Barnes added.
The doctors also discussed the travel times involved for expectant moms, which can be much greater than the often quoted 90 minutes, given road work, closures, and weather. Additionally, Dr. Mark Satterfield said that women who are in active labor cannot be transported by helicopter.
OB nurse Sue Brown said that she has been at the hospital for 29 years and circumstances have changed when it comes to staff. “We used to have core staff,” that the nurses could rely on, Brown said. “Now we have a lot of travelers with varying degrees of skill sets … and they rotate out every 13 weeks.” She explained that it can be a scary situation to be dealing with a challenging birth and not to have assistance from someone she knows and who knows the hospital and its resources. She added, “It’s bigger than OB nurses. We have to get core staff to be confident that someone will be there when you need them.”
After listening to the conversation, Board Chairman Bill Wickman brought up the subject of a birthing center, but questioned how that would change the key issue – a nursing shortage. “We are all very concerned for the program,” he said noting that it impacts not only expectant mothers, but the community as a whole and the viability of businesses reliant on employees. He summed up, “I know we will continue in this diversion period trying to find a solution. Hopefully we can continue to support an OB program.”
In tandem with the staffing shortage, is a housing shortage. Even if employees can be found there is nowhere to house them. This is not unique to the hospital. Feather River College, the school district, the county, the Forest Service, and private employers such as SPI all face the same dilemma.
Board Chairman Wickman suggested that if the hospital obtained a grant it could transform the old Greenville hospital site into one- and two-bedroom apartments for employees. He said some other ideas included adding RV spaces to the area near the proposed skilled nursing facility, and/or providing park model homes that meet the interim need to bring people to the community.
Director Andy Ryback asked about the crew quarters that burned in Greenville. Chief Operating Officer Darren Beatty said that rather than building a single family home to replace the lost quarters, a multi-unit structure could be built.
Beatty added that “there’s a real sense of urgency,” since the financing for the skilled nursing facility is anticipated by my mid-month. While the structure could be built, the anticipated viability of the facility relies upon a high level of residency. “We will need 25 more staff members,” he said. He added that the skilled nursing facility “could cripple the district quite quickly” financially if it’s not operating close to capacity. “If we don’t do something on housing sooner rather than later; it will have a huge impact on the district,” he said.
JoDee Read, who serves both as the hospital CEO and on the school district board of trustees (where similar discussions have been held), said “We need to come at this with a group of folks … PUSD, FRC, the county, us …”
But even if the hospital has the land, is it in a position financially to build housing in addition to a skilled nursing facility, and very soon a new hospital. Beatty reminded attendees that any building the hospital undertakes would cost 40 percent more due to prevailing wage issues.
In the meantime, staff is working on finding rentals to house employees.
Guy McNett, who serves on both the hospital and Feather River College boards, said that FRC is working on building new dorms, which would help offset some of the housing demand in the area.
Community member Rose Massey said she worked at a hospital where doctors and nurses lived on the second floor of a college dorm, which was built through a joint effort. She said that because of limited land, they had a similar complication for finding housing for college students and hospital staff. When asked how it worked to be living above college students, Massey said that she lived in a “really nice one-bedroom apartment with a balcony” and laundry access down the hall. She said no loud music was allowed after 9 p.m. and the living arrangement worked well.
Board member McNett noted the excellent working relationship between FRC and PDH and asked if the two foundations could work together.
Who’s going to pay for it?
The bulk of the building costs for the new skilled nursing facility will come from a USDA loan, but there will still be costs for equipment, furniture, grounds etc. How will that be paid for? And what about a new hospital?
Two ideas have been discussed: a Capital Campaign where the funds would be raised in the community and by major donors, and a bond measure to address primarily the new hospital that must be built within eight years.
“How do you ask the community for skilled nursing?” Board Chairman Wickman asked. “Then how do you turn around and ask the community for a bond for a new hospital?”
Director John Kimmel said that faced with the prospect of not having a hospital, he believed taxpayers would support a bond, but “the state needs to step up and help us.”
Chief Operating Officer Beatty has been working with the legislature to carve out a portion of the state budget surplus to support hospital districts faced with building new hospitals to meet the 2030 seismic requirements. He said if that effort were to fail, a southern California senator has committed to supporting a state bond measure to raise funds for the healthcare districts.
But the clock is ticking. Beatty said that the skilled nursing facility is estimated to take 5.5 years from the initial work to completion. “The hospital will be longer, more complex,” he said. “We really need to commit our own funds to at least start the planning process in a very concerted effort. We have already spent around $1 million on the SNF and we haven’t even awarded a contract.”
No final decisions were made during the meeting.