One day in late spring, Rebecca Davis recalls scrolling through her Facebook feed when she came across an announcement about the arrival of the Buladean Community Health Clinic. It caught her attention because, for her, a visit to the doctor was no simple matter.
“If we go to any doctor’s offices or hospitals, we have to drive 20, 30 miles out of the way,” said the 57-year-old Davis. She moved to Mitchell County from Georgia in the late 1980s and is now disabled. But back when she did work, Davis held down a variety of jobs, from housekeeping and kitchen work to picking cotton and digging ditches.
Buladean is in northern Mitchell County, near the Tennessee border, and for residents here, a visit to the doctor meant a drive over Roan Mountain and across the state line or a half-hour drive to Bakersville. Sometimes Davis would put off appointments to avoid the hassle.
She also tried making telehealth appointments with her doctor in Bakersville during the peak of the COVID-19 pandemic but had trouble setting it up on her tablet. Now she visits the telehealth clinic in Buladean in person, where a facilitator adds a personal touch. This facilitator, known as a telepresenter, handles the technology used in appointments with a remote licensed medical professional.
“Down at the clinic they explain stuff to you. If it takes an hour, that’s what they do,” said Davis. She has gone to the clinic for several checkups, most recently to have bloodwork done, after which she found out that she is nearing Stage 1 kidney disease. “I’m thankful I went,” she said. “If I hadn’t, there’s no telling what shape I’d have been in, in a year.”
Sometimes called telemedicine, this virtual health care uses a range of technology to evaluate patients, including video calls, patient portals, glucose monitors and pacemakers. Such technology has been around in some form for decades, but during the coronavirus outbreak, greater numbers of doctors and patients relied on telehealth.
The era of telehealth during COVID-19
Following the pandemic era shift, several states expanded their coverage of telehealth for Medicaid beneficiaries. Now, telehealth is “more integrated into the Medicaid delivery system compared to the pre-pandemic baseline,” the N.C. Department of Health and Human Services reported in September. But sometimes, wider use of telehealth boils down to other, harder-to-pinpoint factors, such as an understanding of the cultural idiosyncrasies of rural communities.
This is the story of the disparate experiences of two rural telehealth clinics. Buladean and Tipton Hill are separated by a roughly 10-mile stretch of twisting mountain road, but the experiences with their respective telehealth clinics could not be further apart: One has thrived, and the other has floundered. The difference, from the local point of view, may have less to do with technology and more to do with the beloved facilitator assigned to Buladean who has long-standing ties to the area.
There are many reasons that could explain, at least in part, why one clinic has taken off and the other has struggled, according to Amanda Martin North, executive director of the Center for Rural Health Innovation, or CRHI, the organization that funds both clinics. But success in this case is mostly due to one person who, in a manner of speaking, gets the social dynamics and nuances of local culture. In Buladean, that person is Vicki Garland, a Mitchell County native. “When you’ve got the right person for the job, it’s straightforward,” Martin North said.
Buladean: The best of times
Two decades ago, the then-rural health center in Bakersville, the county seat, set up school-based health clinics in Buladean and Tipton Hill serving the school population and the broader community. They operated as an extension of the Bakersville Health Center, with a doctor who made weekly visits and a nurse practitioner who split time between the two sites.
When Mitchell County made the decision to close the schools in Buladean and Tipton Hill amid dwindling student populations, the communities were faced with the same situation. Not only were they losing their schools but also their respective school-based telehealth clinics. Replacing them was on the wish list of residents since that time.
Community leaders in Buladean came together in 2013 to buy its defunct schoolhouse. “The building was in bad shape,” said Dorothy Campbell, a founding member of the Buladean Community Foundation. “When it rained, there were swimming pools in the classrooms.”
As Campbell explained, the foundation secured grants, raised money and little by little fixed up the building. A food pantry went in, the kitchen and dining room were rented out for events. A fitness center received donated weight room equipment from the high school in Bakersville, and there was a game room and a gymnasium. But the foundation always had its eye on bringing a clinic back to town.
It took years of planning, but in late February, the CRHI opened a telehealth clinic in the old Buladean school building, and, so far, the clinic has exceeded expectations. It brings in a steady flow of patients, including repeat patients, with a monthly average of 13.5 appointments through its first seven months. Martin North attributed the positive community response to several factors, though none as significant as the hire of Garland to run the place.
Martin North had initially hired a certified nursing assistant to staff the Buladean clinic. She quit after her first day on the job, leaving the CRHI staff to cover shifts while trying to find a permanent replacement. It took serendipity and some outside networking for Martin North to find Garland.
A job posting made the rounds of church groups and trickled through family connections. Eventually, word got to Garland, a former paramedic for the county. She happened to be in Pigeon Forge, Tenn., about a two-hour drive from Buladean, when her niece contacted her about the job. Martin North told her if she could get to the clinic by 1:30 p.m., she could interview for the position that day. “At 1:15, I am barreling through the door in dirty jeans, work boots and a baseball cap,” Garland said. “I’m here, I want the job,” she told Martin North.
The nursing assistant quit on Monday, and Garland started that Friday.
Tipton Hill: The worst of times
The early success in Buladean is notable, more so perhaps because the clinic in Tipton Hill, also opened by CRHI, has struggled for years. Fewer than 50 patients have walked through its doors since it opened six years ago. It is all the more surprising considering that residents wanted a clinic more than anything else, according to Mike Burleson, chairman of the Tipton Hill Community Foundation. What the foundation did was mail out a survey to community members. “We asked people what they want, and the ones that replied the overwhelming thing was a medical clinic,” Burleson said.
Unlike Buladean, the schoolhouse in Tipton Hill was in such disrepair that it could not be used, so the community ended up renovating an old church building for the clinic. In the beginning, the Tipton Hill clinic was open 15 hours per week, not that it made a difference. Patients weren’t coming.
Looking back, Martin North says organizers made a few missteps that hurt business. “I think we probably put too much emphasis on the fact that it was a telehealth clinic,” she said. While that may have created some resistance, it didn’t help matters that the telepresenter lacked the necessary relationships in Tipton Hill. “The lady that was there initially wasn’t a people person; let’s say she was shy and standoffish,” said Burleson. Complicating matters, Burleson said, she was not from the Tipton Hill area and lacked the necessary relationships to make patients feel at ease.
Tipton Hill is a no-stoplight town surrounded by bucolic mountain farms. The clinic is next to an abandoned textile plant and across the street from Griffith’s General Store. It could be for fertilizer or overalls, an oil lamp or pumpkin seeds, but eventually everyone goes to the store for one thing or another. That’s why when the signage outside the clinic was going unnoticed, and the then-telepresenter was failing to bring in patients, CRHI had the telepresenter go in person to sell cookies at the store in an effort to spread the word about the clinic.
David Griffith, the 30-year-old manager of the general store, figured he would give the clinic a try when he had a sinus infection. “I might as well have been talking to this Pepsi can,” Griffith said of his visit with the telepresenter. That was his only visit to the clinic.
Two clinics, one goal
Stephen North, the founder and medical director of CRHI, previously worked at the clinics in Buladean and Tipton Hill. For several years, he became, in effect, their doctor, but the arrangement ended when the schools closed in 2013. “Ever since the schools closed, people wanted me to come back and see patients in those communities,” North said.
As a practical matter, it was infeasible for North to ever return to practice at either Buladean or Tipton Hill. The cost of maintaining a clinic in Buladean is expensive. A doctor might see two dozen patients per day in nearby Bakersville and no more than six in Buladean, yet both sites would have the same operating cost, he said. As it happens, when the county closed the schools, North was already laying the foundation for a school telehealth program that would eventually bring health clinics back to these towns.
In 2010, he founded the CRHI along with Martin North, who was a board member at the time. Now married, the Norths have overseen the establishment of telehealth clinics in more than 100 schools across seven counties in Western North Carolina. By the time the Buladean Foundation approached the CRHI last June about opening a clinic in the old schoolhouse, the couple said the organization had become experts in developing rural telehealth clinics. They discussed community needs, liability and whether it would make money. It took a few months to hammer out the details until the last day of February, when the Buladean clinic opened in what used to be the principal’s office of the school.
To get the word out, the organization advertised on local radio stations and Facebook, but many people ultimately heard about it by word-of-mouth. “Somebody will come and try us, and then they will call 10 of their neighbors and say, ‘Oh my gosh, what a wonderful service I just received. It’s so quick and so easy, and I didn’t have to go to Tennessee,’” Garland said. There are slow days when not a single patient walks through the Buladean clinic doors, yet the community is fast learning about the clinic services and what it can do for residents. The system is working because it is close and convenient, and patients can walk right in without the wait time typical in most doctors’ offices. “This wouldn’t work without the right people,” said Martin North. Nor would it work without community buy-in. “Buladean wanted us,” she said.
In addition to her duties in Buladean, Garland now attends to patients in Tipton Hill on an appointment basis. The change, while still recent, has been warmly received, and while visits remain low, no more than a couple a month, some locals say they are more likely to use the clinic than before. “Vicki is amazing,” said Vanessa South, a local who said she has been to the clinic several times. “She’s like me, and that makes me feel comfortable.” Garland is assertive when the situation calls for it, but she also understands how to interact with locals. “Mountain people are clannish. You have to know how to speak to them,” Garland said, “and that’s where I fit in.”
The clinics have invested in TytoCare medical equipment, which includes a small handheld device about half the size of the average cellphone. It has a camera and thermometer, an otoscope for looking into ears, and a stethoscope to listen to a patient’s heart and lungs that Garland maneuvers over patients, as a nurse practitioner or provider in a remote location interacts with the patient on an iPad set at face level. The licensed medical professional evaluates, diagnoses and — if the situation calls for it — recommends treatment. Providers can also refer a patient to a specialist and order labs or radiology, for example. Garland is trained to draw blood that a laboratory service picks up.
Toward a common future
The clinics in Buladean and Tipton Hill — at least on the surface — have similarities. The local foundations were invested in their success; volunteers took the time to paint, clean and set up a dedicated clinic space. Martin North and others with CRHI have taken part in a variety of events, among them a pancake breakfast, Easter egg hunt, flu shot clinic, bingo night, yard sale, all to get the word out about the clinics. “In fact, because of our clinic, Country Cablevision ran fiber out to Tipton Hill years before they might otherwise have done,” Martin North said.
With so many similarities, the differences have become all the more glaring.
For one, there is also more going on around the Buladean Community Center, where the clinic is situated, including festivals, a gymnasium, fitness classes, 4-H and Bible study. And then there is Garland. Martin North likened Garland’s place in the community to that of a trusted elder. “She doesn’t work for CRHI so much as CRHI has made it possible for Vicki to help her neighbors intimately, efficiently, locally, and at just the right time and place when they are most vulnerable,” Martin North said.
Less than a year has passed since the Buladean clinic opened, and already it is making itself an indispensable resource for the community. In late August, a middle-aged woman feeling unwell visited the clinic. “When she walks in, I note that she is very pale,” Garland said. “I also know her. She’s a diabetic, so I’m thinking it may be some diabetic problems, but she was also short of breath and having left arm pain.” Garland gave her aspirin, checked her files and determined that the woman’s condition was dire, so she called 911. The woman was rushed to the hospital, where she had a triple bypass and is still recovering. As Buladean Community Foundation member Campbell sees it, Garland had saved the woman’s life. “It means a lot to have someone there who people can come to in an emergency,” Campbell said.
On some days, Garland has no scheduled appointments or walk-ins, which means the clinic is making no money. The reality is there is little money to be made running a telehealth clinic in places like Buladean and Tipton Hill. The clinics bill insurance when they can and others pay a sliding fee scale. But there is little money in running a telehealth clinic in places like Buladean and Tipton Hill. But a benefit of operating a business independent of a large medical system is being able to make decisions independent of revenue and efficiency. “I’m not subject to ‘this isn’t profitable, scrap it’ type of scrutiny from a boardroom that has no idea what we’re actually doing,” Martin North said. “I cannot imagine the time when a giant medical company will run thousands of rural clinics at a profit.”
Even though Buladean doesn’t generate significant revenue for CRHI, according to Martin North, it doesn’t cost much to keep it open either. The money the nonprofit generates from its school-based telehealth clinics that serve students, faculty and staff, as well as the nursing, medical and behavioral health care it provides to the Madison County Jail, is more than enough to cover the cost of keeping the Buladean and Tipton Hill clinics open. “As long as I come out in the black, we’ll keep going,” Martin North said.
The tragedy of the pandemic helped thrust telehealth into the popular consciousness, something Martin North says the most sophisticated marketing budget could not have accomplished. The U.S. Department of Health and Human Services relaxed some rules governing how telehealth is used during the pandemic, which helped expand the reach of telehealth services. Billing restrictions that had kept Medicare recipients from using telehealth in some rural locations were loosened, while federally qualified health centers and rural health clinics were allowed to provide telehealth services to Medicare recipients regardless of where the patient is located. While this was happening, the U.S. Government Accountability Office found that the number of telehealth services for Medicaid beneficiaries increased more than 15 times compared with pre-pandemic levels in several states. The changes made during the pandemic have been extended to the end of 2024.
Whatever the future holds, the success of telehealth in rural landscapes, inasmuch as Martin North can imagine it, will likely be determined by locals coming up with solutions that best meet the needs of their communities. “The magic and frustration of rural places is the clannish behavior that is suspicious of outsiders,” Martin North said. “Telehealth becomes a solution to be applied by rural communities to bring in what they need.”
This was funded, in part, by the Community Foundation of Western North Carolina.
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