The Greeley County Health Care Services program began as a small 18 bed community hospital, operated by the Great Plains Health Alliance and a sole provider, private Family Medicine clinic. Dr. Willard Werner left the community he had served for over 30 years in 1991 and the sole remaining Family Physician; Dr. Robert Moser, M.D. continued to provide local clinical, hospital, emergency room, obstetrical and long-term health care services. In late 1991, the sole physician in Wallace County Kansas, Dr. Chung retired as well after 30 years of service. That community came to the Greeley County Hospital administration and Dr. Moser to discuss keeping their small clinic in Sharon Springs open. This request resulted from a Wallace County Economic Development Office survey of community members, more than 60% of whom sided with participating with Greeley County and Dr. Moser for their health care needs. The value of maintaining a presence in that community, not only for the health care needs of its citizens but for the ongoing health of the local Greeley County Hospital was evident so it was agreed that Dr. Moser would establish a clinic in the existing Wallace County clinic. Dr. Moser began seeing patients one-half day a week in Sharon Springs in January of 1992. Additional provider coverage was arranged with the assistance of a mid-level provider for nine months until the mid-level provider left. Then Dr. Moser began seeing patients in the Wallace County Family Practice Clinic two half-days a week. Urgent care and emergencies in Wallace County were dealt with through the clinic and local EMS service. Meanwhile, Dr. Moser assumed the County Coroner position and Medical Director of Prairie Manor, the local county owned long-term care facility. He also supervised the County Health Officer who was the County Nurse.
The community leaders in both communities, through a state grant, formed the Integrated Community Health Development Project in 1992-1993, with the assistance of the Docking Institute in Hays, Kansas. The citizens of both communities participated in group discussions and surveys and the results gave the communities a vision of where a coordinated and integrated health care system could be in such a rural setting with planning and focus. Some of the services the communities felt they needed were home health services, assisted living, behavioral health and of course additional primary care providers. It was hoped that the current outreach clinics in cardiology and urology could be expanded to include gynecology, orthopedics and neurology.
Additional recommendations were to maximize reimbursement for services, perhaps looking at the EACH/PCH program. At that time the limitations to length of stay and the inability to provide surgeries was contrary to the direction that the hospital and Dr. Moser wanted to go in expanding services and access. The Wallace County Family Practice Clinic was started as a Rural Health Clinic, but the vagaries of that system, particularly requiring a mid-level provider didn’t work out, so the RHC status was allowed to lapse in the year after Dr. Moser lost the assistance of the mid-level provider in Wallace County in September of 1992. Additional efforts to help with reimbursement and recruitment centered on getting Greeley County designated as a Health Professional Shortage Area or HPSA. The government looked only at the county population in their consideration, despite the two county practice and catchment area of the practice.
The regional HRSA office and National Health Service Corps staff assisted with this process and suggested we look at getting Wallace County designated. This was completed and the designation turned out to help in recruitment as well on reimbursement issues.
One such site visit by Dr. Wendel Ellis, D.O. and his wife Elby, occurred on a cold, gray January day; the same day Dr. Moser and his wife Dalene were having their second child. Not having as much time to visit face-to-face with the Ellis’s, Dr. Moser could only tell them that Dr. Ellis would love the challenges and variety of rural family practice and his wife would like the family oriented life-style of a small community. With one child of their own and another on the way, the group felt the visit was the best one yet but knew they would have a long wait before the final decision came. Luckily, Dr. Ellis and Elby felt that Wallace County’s HPSA designation would fulfill his National Health Service Corps loan re-payment agreement and the practice opportunity looked like what they had been searching for; a practice with another family physician who did procedures and obstetrics. Tribune and Sharon Springs were listed as medically underserved by the State of Kansas and that would fulfill another role by allowing Dr. Ellis to participate with the State’s Bridging Program. This connected physicians coming out of training in Kansas residency programs with communities in need and provided a stipend the last two years as well as a signing bonus. Half of the funds came from the state and half plus the signing bonus from the community. The Ellis’s called back only 2 days after their visit to announce they would be coming after completing residency, a year and half later.
Dr. Ellis joined the practice in July of 1993 under a guaranteed income contract with the Greeley County Hospital. Dr. Moser and the hospital agreed that the costs of purchasing supplies and equipment could be prohibitive, so a unique arrangement was made where expenses were paid off based on the provider’s share of the income. After two years it would be assumed that the supplies and equipment purchased would be evenly divided. Dr. Ellis served two, two-year loan-repayor terms for the National Health Service Corps. Access to care for the underinsured and uninsured was addressed through a sliding fee scale as part of the practice agreement with the NHSC.
Soon, Wallace County Family Practice went from having a provider one day a week to one, four days a week. Physician availability in Tribune doubled as well. The on-call schedule was split to one week on and one week off, which was a great relief to Dr. Moser. The local services expanded as well with the physicians now having time to schedule and complete their own treadmills and scopes. Dr. Moser was able to continue to do tonsillectomies as having a second physician meant someone could cover the emergency room and other urgent care issues without worry of interruption. With both physicians trained to do cesarean sections, patients and their physician no longer had to worry about getting a surgeon to come to Tribune to do their sections or travel by ambulance to the nearest referral hospital in Garden City, 85 miles away. Dr. Ellis assumed the medical director positions for the Wallace County EMS, Prairie Manor and the County Health. Dr. Moser held the same positions in Greeley County.
The HPSA designation helped recruit another physician assistant, Kevin Iseman, through the National Health Service Corps as a loan re-payment recipient. Kevin joined the practice in July 1997 and served until July 2000. Finally, Chris Hansen, R-PAC was recruited to Wallace County and joined the practice in July of 1999 and served until 2004. He lived in Wallace County and covered many after hour’s calls and weekends from his home there. He often rode down in the ambulance with patients, not so much for the urgency but to reassure them during their transfer and to assist our volunteer EMT’s. Now there were more provider hours available in Wallace County than they had ever had, while the clinic in Tribune had two providers each day with the addition of a part time mid-level provider, Kathy Bangerter ARNP in 1997. Dr. Randall Fahrenholtz joined the medical team in June 2005. An experienced healthcare provider, Dr. Fahrenholtz brings an enthusiasm for rural healthcare and an appreciation for the rural lifestyle.
The increasing numbers of patients being seen immediately began to benefit the hospital and its ability to develop more services. The hospital and doctors recruited a physical therapist, Brian Miller RPT, in 1997 to provide therapy in Greeley County. Brian was originally from Tribune as is Dr. Moser. This branch of health service now has satellite offices in Sharon Springs and Leoti. A local physical therapist has enabled many residents to return to their homes sooner following surgery as they can benefit from therapy locally. Greeley County Home Health officially began in 1997 as a branch of the Greeley County Hospital. They were soon seeing patients in the three surrounding communities.
Meanwhile, plans in Wallace County and Greeley County continued to move forward. Dr. Moser, Dr. Ellis, and Dr. Fahrenholtz are very visible members of both communities. They are joined in this commitment by the other providers associated with the practice. A 1998 NHSC survey showed that community members felt they had a high degree of social capital, “the trusts, networks, and involvement of community members to solve their problems” and over 90% of respondents reported being “satisfied” with both the quality and results of their health care.
Greeley County Health Services was very fortunate to participate in the National Health Service Corps 25th Anniversary celebration. The practice was one of seven across the nation highlighted through a social reconnaissance and community survey. This experience not only provided valuable information directly from and to the community about the current state of our healthcare needs but served as a turning point in organizational development. GCHS was able to build on the strengths of our system and the documented needs of our residents to develop programming that was attractive to potential funders such as Health Resources Services Administration, the Kansas Health Foundation, and others.
Wallace County built a 1.7 million dollar retirement home in 1999. A major selling point for incoming residents is the availability of quality healthcare. A 4.2 million dollar bond issue was approved in Greeley County that remodeled the old nursing home into a new clinic with room for outreach clinics as well as a larger lab, x-ray and even a CAT scanner room. The new nursing home for 32 residents and 4 assisted living apartments attached was built where the old hospital and clinic operated. This facility is located on one block and also includes a new ER and hospital entrance. This was completed in October of 2000.
Dr. Moser and Dr. Ellis’ influence has spawned the creation of a health care interest group called the Greeley-Wallace County Healthcare Foundation. Residents from Greeley and Wallace County, in support of the health services in our area, formed this private foundation. The formation of a Health Foundation, the Greeley-Wallace County Healthcare Foundation (GWCHF) was completed in 2000. The foundation has grown over the last several years and as a result has provided scholarships to local students, equipment and support to the healthcare services in our area. Currently this group is working to construct a new medical clinic in Wallace County and has collected over $630,000 towards this effort. Construction of the facility will begin in spring 2006 and will include space for medical, dental and physical therapy in Wallace County.
Although the doctors could simply take satisfaction in the results of their work to stabilize the local healthcare system and the economy, they continue to be active in educating others about the problems and benefits associated with rural healthcare. Dr. Moser served as President of the Kansas Academy of Family Physicians in 2001 and is a passionate advocate for rural healthcare. He is a volunteer Clinical Assistant Professor with the Department of Family and Community Medicine, University of Kansas School of Medicine-Wichita. He and the other physicians serve as rural preceptors for medical students and occasionally for physician assistant students. Dr. Moser testified before the Senate subcommittee on Public Health in March of 2001 regarding the importance of such programs as the National Health Service Corps in supporting the safety-net providers who care for the underinsured and underserved groups. He received the National Health Service Corps Program Director’s Award in 1998. Dr. Moser also received another great award in 2006 when he was named as the Kansas Academy of Family Physician’s Family Physician of the Year. Dr. Ellis is a founding director for the Kansas Clinician’s Network, a statewide group designed to assist in the difficulties associated with rural healthcare such as professional isolation and lack of resources. He has also served as President of the Midwest Clinician’s Network, a multi-state organization designed to improve communication among medical providers. Dr. Ellis has recently taken a leadership role in the Foundation for Healthcare Access. This organization is still in its infancy, but will help to provide a face, voice, and expert opinion on matters relating to health care access and to represent clinicians who provide health care to the underserved. Dr. Ellis was awarded the National Health Service Corps Award for Excellence 1995 and HRSA’s Primary Health Care Administrator’s Award 2000. Dr. Fahrenholtz has quickly gained a very loyal following in the community in his first six months of practice. He has also demonstrated a real interest in furthering patient care when possible and has taken a lead role in the development of a cardiovascular program for intermediate and high risk women in our area.
Meanwhile, active participation by Dr. Ellis with the National Health Service Corps and the Kansas Association of the Medically Underserved opened the opportunity to grants. Chrysanne Grund began to develop programs and write grants for the organization. The first grant awarded was the Prescription Drug Purchase Assistance Program, from the National Association of Community Health Centers. It worked largely because of the efforts of the local pharmacist, Chris Dixon in Tribune. For almost 12 months, patients to the Wallace and Greeley County Clinics received their prescription medications without cost. This was a benefit to both communities and patients from surrounding communities who received healthcare through the Greeley County Hospital that totaled almost $998,000. Although the program was for a limited time only, it did offer significant evidence to show what an impact having affordable medications, counseling and routine medical care can have on improving health care.
With community education programs by Dr. Ellis and Dr. Moser, a grant from the Kansas Health Foundation paid for a laptop computer and LCD projector. This equipment is invaluable when working with patient education groups on topics such as cardiovascular disease, diabetes, and asthma. Chris Hansen RPA-C, started an athletic training program in the local Sharon Springs school, which trained high school students to respond to minor medical emergencies and the health care needs of student athletes. Chris also served as President of the local hospice board in addition to volunteering on the local fire department. The Greeley/Wallace County Healthcare Foundation was able to secure funding to support the Athletic training program in 2001, 2002 and 2003. Chris Hansen received an Innovations in Healthcare award from the American Academy of Physician Assistants in 2002.
Another successful grant application to the National Health Service Corps Commissioned Officer Program, led to the recruitment of the third physician in July 2001, Family Physician and Commissioned Officer Julia Watkins, M.D.. Dr. Watkins quickly joined in the efforts to increase access, including those without insurance or who were less likely to seek medical care until an emergency arose, such as the Spanish speaking population and feedlot and dairy employees. Dr. Watkins created a “dairy clinic”. She traveled to the local dairy feed yard and provided free medical care to employees and their families. This employee population is largely immigrant and helped to introduce them to the benefits of regular healthcare. She started a free ? day clinic at the local dairy accompanied by the office nurse from the Wallace County Family Practice Clinic, Burlay Parks, R.N.. Burlay was one of the original office assistants Dr. Moser hired when he started the WCFPC in 1992. She was assisted by the clinics and the Greeley County Hospital in getting her RN degree in 1998. Through an individual agreement, she provided services in exchange for loan forgiveness. Dr. Watkins was appointed as a Ready Responder for the State of Kansas and was reassigned to another community in 2004 following completion of her three year term at GCHS.
Another significant developments and the last piece to the community health survey needs analysis in 1993, includes the addition of a behavioral health provider to the staff and connecting the healthcare providers between the two communities. The Greeley County Hospital health care system informally became Greeley County Health Services and was awarded a Community Access Program grant in 2001, funded through Health Resources Services Administration. The grant became known locally as the HealthCAP program and consisted of two goals; one included the addition of a behavioral health provider and support staff and another, a wide-area network to link all the health providers. Not only did this CAP grant allow the recruitment of a behavioral health provider, but a community health resource specialist who could assist patients with prescription assistance, insurance and other care giver issues. This greatly lightened the load the physicians and nurses had to deal with in the clinic setting regarding these issues to access. A patient educator was added in 2002 and helps in dealing with many of the other high demand areas such as diabetic and chronic disease education. By integrating behavioral health services directly in the primary care setting, they have reduced the stigma often associated with mental health counseling, especially in a rural area. Patients now have access to counseling directed by the primary care provider, whom they know and trust. This innovative program was developed by Dr. Moser, Ann Schumacher, L.S.C.S.W. and the HealthCAP staff with help from outside technical assistance. Angela Woelk, LSW, MW now fills the position as our Behavioralist.
The second portion of the CAP grant was to integrate all the health care providers and organizations in the two communities. A third community was added to the final project when Syracuse, Hamilton County, south of Tribune lost their physician providers and asked the physicians to help cover their mid-level provider, Steve Sager R-PAC. Again, additional time for rounds and chart reviews was added to Dr’s Moser and Ellis’s usual responsibilities. This arrangement lasted 12 months until another arrangement was made with rotating locum tenum doctors and another family physician was recruited to Syracuse.
Dr. Ellis recruited the local computer store owner, Warren Kuttler, and outlined a plan for such a computer network as well as all the hardware and software needed. Dr. Moser researched the various software programs that might fit into the plans. The network program began in 2001 and by September of 2002 it was up and running. Now the two clinics share the same patient chart and practice management software, as if it was running locally. With the security of the software package, it allowed EMS to see the demographics of a patient, such as insurance, allergies, medications and current diagnoses. County Health could put down interventions such as immunizations on a patient’s chart and the provider would see it the next time they pulled it up. Patients who had only been seen in Wallace County could have their entire chart printed out if needed before they arrived in the ER from an ambulance call. The network is truly leading to actual integration of the health care in the two communities. The providers now believe they have the parts in place to implement an improved level of patient care by working on a chronic disease management program. The computerized medical records, availability of behavioral health care, a patient educator and a health resource specialist will help to solidify the development of this plan. Recent surveys in the two communities have shown a higher incidence of heart disease, obesity and diabetes than in the state of Kansas. Plans are developing for a comprehensive approach to patient-centered care, incorporating these components. Through the Bureau of Primary Health Care, the Wallace County Family Practice Clinic has participated in the Cardiovascular Collaborative since April of 2001. This experience with clinics and programs across the nation has helped to provide assistance in developing many of the chronic disease treatment modules currently in place.
GCHS’s most recent award is to be named as a National Community Center of Excellence in Women’s Health. This grant was awarded to only two community sites in 2004 and GCHS is the only frontier site in the country. This five year program will allow Greeley County Health Services to continue many of the service initiatives started under the HealthCAP program and expand to other areas of education, leadership and empowerment for young girls, women and their families.
In December of 2002, the hospital was able to purchase a refurbished CAT scanner from St. Catherine’s Hospital in Garden City and now has it in operation in the Greeley County Hospital. The hospital participates in the Pioneer Health Network, a network of 17 local health care systems including St. Catherine’s. A mammography unit was incorporated in 2005 and provides screening mammography services to local women.
The only health care provider the communities have yet to retain is a dentist. There have been dentists in Tribune. In fact the hospital provided facilities for the last one who left in 1999 and recruitment efforts are ongoing. One of the biggest obstacles to a private dental practice in this part of the state is the large Medicaid population in need of dental services. Many of the private practice dentists do not accept Medicaid and the only Medicaid provider in west-central Kansas has a tremendous demand for her services. The construction of the clinic facility in Sharon Springs may facilitate this recruitment process.
The growth in services and the economic impact the Greeley County Health Care Services and its clinics and providers have had in the service area they cover has been tremendous. The average patient census in the hospital in 1992 was 1.8 patients; there were 50 hospital employees and 6 clinic staff. The yearly gross income for the hospital was $400,000.00. Now the Greeley County Health Care Services team consists of 120 employees, including the clinics, hospital and LTC, in two counties and the average patient census is over 3.5 with last years gross income for the hospital close to 8 million dollars. Economic difficulties in the farming and ranching economy as well as in general has not made this transition easy for the communities, but the support has been outstanding. Medicare and Medicaid reimbursement issues towards rural practice have also taken a heavy toll on the funds available to support continued growth, but the Greeley County Health Care Services became a Critical Access Hospital in 2003. The clinics also regained status as Rural Health Clinics in 2005 which provides much needed cost-based reimbursement. Now that the restrictions on procedures, surgery and length of stay have been lessened, it should help continue the strong program that these communities have forged.
Plans for the future include continuing this strong tradition of healthcare excellence with solid financial management and a business structure built to survive the changing insurance reimbursement environment. The leadership has organized a Management Team to lead the healthcare system. Behavioral healthcare integration is quickly being recognized as an effective means of delivering care to patients. However, most insurance companies do not provide coverage for this valuable service. Greeley County Health Services leadership is committed to continuing the program and must now navigate the insurance system to gain appropriate coverage. This may include networking with other Kansas-based programs and providing education about the process. There remains both a need and an opportunity to create comprehensive patient and intervention programs for those with chronic disease. GCHS also has displayed a strong commitment to the economic future of our communities with members of the physicians, administration and staff participating in the community economic development efforts in Greeley and Wallace Counties.
Greeley County Health Services is an outstanding example of what can be accomplished when communities band together to support and sustain their healthcare services.