Unintended Consequences of Rural Obstetric Hospital Closures

With many rural hospitals closing their doors over the past twenty years for a variety of reasons, pregnant people living in these rural areas at risk for poorer outcomes.

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Rural hospitals have been closing their obstetrical units en masse over the past twenty years. Across the United States, there are many reasons for this, such as physician and provider recruitment; hospital budgets cannot afford obstetric services; changes in population growth resulting in fewer young families. Whatever the reason, one thing is certain—pregnant people living in rural areas are at risk for poorer outcomes and the impacts that rural healthcare can create.

I recently spent several days in rural Iowa learning about (and experiencing) the unintended consequences of obstetric hospital closures. In Iowa alone, 40 birthing units have closed since 2000. In 2000, 77 out of 99 counties in Iowa had a birthing unit. By 2021, that number was 46 out of 99. And again, these reasons were varied and many—lack of provider recruitment, budget cuts, tort reform, and others. Many studies representing rural America continue to describe pregnant people as having to drive or travel for hours to reach obstetrical or well-woman care. Lack of resources has left these individuals to seek out care far from home. But a statement made during my visit resonated with me.

What about the pregnant people who do not have the means to travel? What if they have no transportation, or cannot afford gas? They are those left behind in rural healthcare closures.”

This statement has been a part of my waking thoughts for days now. And while we speak of long commutes for seeking healthcare, we rarely discuss those who cannot travel, or who cannot afford to travel. We are so busy describing long journey times that we have forgotten to describe those who cannot journey at all.

And we assume that everyone has reliable internet access. “Just sign rural patients up for telehealth.” If it were only that simple. While most of us maneuver through our latest phones (which are supercomputers slightly larger than a deck of cards) or enjoy hassle-free Wi-Fi in our homes, we forget that not everyone in rural America is as fortunate. Telehealth relies on a strong internet signal that can carry video conferencing and a mechanism to refer to specialists or resources that may not be available locally. While COVID-19 had heralded a new era of telehealth, not everyone has jumped on the bandwagon. Both providers and patients included.

Many have described solutions to this issue, which tend to be multifaceted and require considerable resources and deliberation. But there are some learning moments that I would like to share with you that deserve greater attention:

  1. During the past six years, I have had exceptional teachers, mentors, and guides throughout the rural health space. Departments of Health traditionally have been my best coaches and have provided an exceptional depth of understanding. I would strongly encourage hospital teams to engage with their Departments of Health at a much greater frequency to partner in achieving optimal maternal health outcomes in the community (but that is another story). And quite frankly, this is a recommendation I would make regardless of location (urban, rural, suburban, etc.).

  2. Here is an example of how policy can impact a state or region: Iowa is 50th out of 50 states for practicing OB/GYN providers in the state. Recruiting providers, particularly physicians, to rural communities can be a tough proposition. But this also extends to reasons why recruitment can be difficult. Tort reform and medical malpractice insurance can make it almost impossible to practice, particularly for high-risk services, such as childbirth. But when services are no longer available because of these types of barriers, who is it that suffers?

  3. Speaking of the Department of Health, I visited Wyoming Medical Center in Casper, Wyoming for a site visit back in 2018. Team members from the Wyoming Department of Health were spectacular and provided great insight into their state and remote/frontier communities. During my two days there, the Department of Health teams had only one request of me:

Get in your car and drive east on Interstate 25. Drive for one hour, and then drive back. And let us know what you think.”

I drove for one hour. And do you know what I saw? I saw some of the most awe-inspiring geographies I had ever seen. But I also saw nothing. A few gas stations, some farms, but other than that, nothing. And that was the whole point of the exercise. Access to medical care is tactical and requires a different type of thinking and planning in frontier communities. And that was during the summer when helicopters had relatively no barriers to flight. With no snow. And no blizzards. And again, that is a different story.

I say all this to come back to the beginning. I have had such remarkable and memorable intersections with rural health. I am certainly not the expert, but there are experts to whom we must listen and respond in kind. And if there is a message I want to relay from the experts, it is this:

There are unintended consequences of rural obstetric closures. We cannot forget that while we describe the hours-long journeys of pregnant people seeking care, we cannot forget about those who cannot make the journey in the first place and are left behind.

We cannot afford for zip codes to determine the outcomes of pregnancy, and for those who pregnancy impacts. Find your experts. Listen to their stories and make a plan to advocate for those whose voices cannot be heard over a distance.
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Social Determinants of Health & Maternal Health: Remember Who is Caring for our Patients

Social Determinants of Health (SDOH) such as transportation, housing and education have an impact on the health of individuals and communities. Z Codes used to distinguish SDOH can improve the accuracy of treatment and contact with healthcare.

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Maternal Health Overview

In 2017, National Public Radio (NPR) and ProPublica Lost Mothers series forever changed the landscape of maternal morbidity and mortality conversations. Suddenly, maternal mortality data had a face, had a family, and had captured the media by storm. In short order, the New York Times, USA Today, and other national publications were also reporting on maternal mortality. For years, those working in obstetrics and obstetrical care had been signaling the alarm related to increased maternal mortality rates. And as the Lost Mothers series continued to introduce the country to mothers who had died during or after childbirth, a similarity began to take shape: many more of these mothers who were dying were Black or Brown women. Since that time, there have been many academics, clinicians, and community members seeking to bring awareness, recognition, and funding to support research and community-led initiatives to reduce the disparities in maternal death. One of these areas is that of Social Determinants of Health (SDOH).

Z Codes

There’s quite a bit of discussion surrounding Z Codes these days. What is a Z Code? Well, technically, Z Codes are ICD-10 Codes that can improve the accuracy of medically necessary treatment and contact with healthcare. And there are a lot. Z Codes cover Z00 – Z99.

Z Codes for Social Determinants of Health

Did you know that as of October 1, 2021, there are 109 Z-codes available for Z Codes 55-65? One of the challenges organizations find with Z code documentation for SDOH is the number of Z codes and various screening tools available. Screening for SDOH is a skill that must be practiced in a sensitive and HIPAA-compliant manner and followed through with a structured plan for referrals. If you have not had the opportunity to view SDOH categories lately, here is the most up-to-date listing. Which Z-codes do you find most regularly in your documentation?

Z55 – Problems related to education and literacy.
Z56 – Problems related to employment and unemployment
Z57 – Occupational exposure to risk factors
Z58 – Problems related to physical environment
Z59 – Problems related to housing and economic circumstances
Z60 – Problems related to social environment
Z62 – Problems related to upbringing
Z63 – Other problems related to primary support group, including family circumstances
Z64 – Problems related to certain psychosocial circumstances
Z65 – Problems related to other psychosocial circumstances

Within these categories are additional discrete health determinants. Let’s use Z58, Problems related to Physical Environment. There are 19 sub-elements within this code, including homelessness (sheltered and unsheltered), food insecurity, extreme poverty, and discord with landlord/neighbor, to name a few. Problems related to Physical Environment are one of the most utilized Z-Codes we find reported within the NPIC database.

In 2019, the National Academies of Science, Engineering, and Medicine (NASEM) released the report Integrating Social Care into the Deliveryof Health Care: Moving Upstream toImprove the Nation’s Health. This report highlights the upstream effects of housing, transportation, food, and upbringing (to name a few) on the health of individuals and communities, and those impacts on the delivery of healthcare and outcomes. One of the key takeaways of this report is the ability of hospitals and health agencies to integrate social care into health care. The Consensus Guidelines recommended five (5) activities healthcare organizations can weave into their SDOH framework:
  • Awareness
  • Adjustment
  • Assistance
  • Alignment
  • Advocacy
Remember the rural health discussion last week, and transportation challenges? Let’s use that example to work through this framework:

Awareness: Have you asked your patient about transportation to and from appointments? How long is the drive? Is there reliable transportation even available?

Adjustment: Is there a way to reduce the need for in-person appointments? Is Telehealth an option? If not an option, how can providers adjust or refer to ensure the patient is receiving the care needed?

Assistance: Is there funding available for transportation? Medicaid vouchers? Access to local programs to support the internet or other communication devices needed to interact with telehealth?

Alignment: Opportunities for hospitals or systems to invest in ride-share or other transportation programs? Or partnerships with cable or satellite providers to set up connections for telehealth.

Advocacy: Creating connections with local/regional/state entities to create and support programs that can provide transportation access or availability of healthcare to remote or underserved regions.

So, how can we make a difference and help to tell the story of unmet social needs of pregnant patients in our communities, and connect these stories through data?
  • Select a few social determinants of health that you and your organization want to focus on. Do your teams know what a Z Code even is? When was the last time you explored the Z Codes your hospital collects? And beyond that, stratified them by race and ethnicity?
  • Sometimes, 109 codes can feel overwhelming to track. Are there specific unmet social needs that are more pervasive or create barriers to accessing healthcare? Pick 3 and focus on those to start.
  • Involve your community in discussions surrounding what SDOH you want to begin tracking. “Never about me without me” is a frequent statement used by patient advocacy groups. When was the last time you asked your patients about what their needs are?

Social Determinants and Healthcare Teams

Let’s not forget your care teams and staff. When was the last time you surveyed YOUR HEALTHCARE TEAMS about their own unmet social needs? How many buses do your team members take to get to work? Have they been anxious about paying rent? Utilities? Have they had to make decisions about whether to buy food or medicine with their paycheck? You may assume that because your employees work in a hospital that they automatically have the resources to live and thrive in the community. Your teams take care of your patients’ needs every day. If you are not surveying your teams on SDOH and unmet social needs, you are not caring for your entire community.

Remember, caring for pregnant patients and assessing for their social needs requires a strong and resourceful healthcare team, whose own social needs can be assessed just as vigorously. It takes a village to care for our communities. And our own healthcare communities.
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