Jared Chaffin knew last spring that his hospital’s budget would be stretched thin. As CEO and CFO at Warren Memorial Hospital in Friend, Nebraska, he brought his concerns to leaders and board members as soon as he could.
“What I was looking at did not look good, and I had let our administration know,” Chaffin said. “When you're able to make payroll, and that's it, and you can't make vendor payments, it's kind of obvious you're in trouble.”
Insurance reimbursements were running low, and hospital leaders were weighing their options long before it came to a head last July. Hours from not being able to make payroll, it became a race against time to keep employees.
“I know there's nothing any of us could have done at that point, just time had finally caught up to us,” Chaffin said. “We had quite a bit of reimbursement that we were waiting on to come in, and it just had not come in yet.”
Almost immediately, leaders met to submit an application to transition from a critical access hospital to a newly introduced model, a rural emergency hospital.
It meant losing inpatient procedures, but it also meant saving the emergency department. Without one in Friend, people in and around town would need to drive at least 30 minutes to access critical care, a life-threatening window of time.
“Going REH meant a lifeline, and the potential for our (emergency department) to be there years into the future, that is what really drove this decision,” Chaffin said. “If we weren't here, there’s a great potential an emergency patient would not make it 30 minutes down the road.”
Rural emergency hospitals operate on an annual budget of $3.2 million from the federal government. All other revenue has to be generated by the hospital through services such as outpatient clinics.
“You do have to have a wide range of outpatient services. That is where you're going to bring in that extra revenue to make everything happen,” Chaffin said. “Going REH, we've been able to kind of focus on that, and try to grow it.”
It’s not a common designation. Nationwide, there’s less than 30 rural emergency hospitals.
Jed Hansen, executive director of the Nebraska Rural Hospital Association, said that out of the 64 eligible hospitals in the state, six would financially benefit from making the transition.
“There's a lot of other factors depending on what the medical staff in the community is wanting to do, what the community itself is wanting to do, but about 10% of our state's rural hospitals would likely benefit financially from that conversion,” Hansen said.
A new designation means a new system of care, something nurses have to adapt to, according to Amy Thimm, who’s a registered nurse and the chief clinical and operating officer at Warren Memorial.
“This is a different type of nursing, a different type of health care,” Thimm said. “So we all had to get used to that. We're still getting used to that.”
While Warren Memorial’s application was processed, the city provided emergency funding to keep the hospital afloat.
That decision wasn’t made until after hospital and city leaders brought the problem to the community. Jewels Knoke, mayor of Friend, said it was a difficult decision to make.
“You're weighing a lot of ‘Do we take this money that we would like to use for our infrastructure, for other things that the community has needed for a while and put that towards the hospital?’ It took a lot of conversations,” Knoke said.
As an EMT, Knoke knew the only way to save the hospital was to “stop the bleeding.” Without fixing the problem at hand, the hospital never could have stayed open long term, she said. If the hospital lost its emergency room, residents of Friend and surrounding communities would lose critical care.
“At the end of the day, we stopped the bleeding," Knoke said. "Now we're able to thrive and move forward and know that my people have an ER to come to. And the small communities around us that use us for that stabilization, those people have a greater chance of survival than they did if our doors closed. That's what it boiled down to, we have to keep these doors open or lives are at stake.”
Without inpatient services, residents rely heavily upon the emergency department and outpatient clinics to keep them healthy. It’s a slow process, Chaffin said. Hiring specialists isn’t the difficulty — it’s ensuring their schedules are full.
Caleb Schroeder is a general surgeon based in Hastings. He grew up in rural Nebraska and saw the sacrifices people across the state make to go to health care appointments.
“They have to work around their schedule in order to fit in a lot of stuff, and a lot of that includes health care. That's a piece of the puzzle that I have seen firsthand,” Schroeder said. “It's a piece of the puzzle that I respect.”
He spends time driving from Hastings to clinics out of town. The drive to Warren Memorial is about two hours roundtrip. It’s an opportunity Schroeder welcomes, though, despite the time sacrifices.
“When I make commitments to going to a place like Friend, it's with the understanding there will be times there is one patient on the schedule, there'll be times that there's 10 and I think all of us really have that commitment to providing the care for the patients a manner that both fits their needs as well as ours,” he said.
Balancing finances with patient and community needs can be difficult, but the switch to becoming an REH has offered a new solution, Chaffin said. Now, hospital staff and leaders are learning how to continue moving forward.
“I would love to finally stop treading water and be able to swim," he said. "And I think we're on our way. We still have a lot to do. Every day is a new challenge, we learn something new. Every day, I feel like we've we have come so far from where we were a year ago.”
With an operating room ready for renovations and eyes set on expanding outpatient services, hospital leaders hope to bring big-city health care to small-town Nebraska.