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Creating a Blueprint for Rural Health

MAHEC’s Rural Teaching Practices Improve Access to Care in WNC

Dr. Jessica White is a flurry of activity on this warm summer day. After completing a note in a patient chart, she heads down to a small classroom at Celo Health Center, a small but bustling family practice nestled in the Blue Ridge Mountains in Yancey County, one of Western North Carolina's most rural and underserved areas.

Just outside the window, the mountains are almost completely obscured by a lush hardwood canopy that provides shade for patients sitting on the rocking chair porch of this federally qualified health center. The melody of bees and wildflowers welcome Jessica's colleagues from the Mountain Area Health Education Center (MAHEC) who begin to arrive for lunch and continuing professional development.

One of the first is Gwen Seamon, PharmD, a second-year pharmacy resident. Gwen is leading today's discussion on how to integrate clinical pharmacy services into rural primary care practice. She is accompanied by Courtenay Wilson, PharmD, director of MAHEC's second-year pharmacy residency program, and Benjamin Gilmer, MD, MAHEC's rural fellowship director. All three have traveled from the main campus in Asheville for today's didactic.

A few minutes later, Patricia Hall, DO, joins the group. Dr. Hall is a rural fellow who has been with the Celo Health Center for almost a year. She's also a fellow in the Academy of Wilderness Medicine and has just spent the morning leading a wilderness medicine simulation for rural high school students attending a MAHEC health careers summer camp.

Kacey Scott and Vanna Labi are next to arrive. Kacey is a first-year medical student and Kenan Primary Care Medical Scholar at the University of North Carolina's School of Medicine. Vanna is an NC AHEC Scholar about to begin her first year at UNC Gillings School's Master of Public Health Program in Asheville, which is located at UNC Health Sciences at MAHEC.

Everyone grabs something to eat and takes their seat while Gwen connects her laptop to the practice's A/V system and providers from Celo's partner practice, Bakersville Community Health Center in Mitchell County, join the group via videoconference.

Elizabeth Peverall, MD, MPH, and Philip Mitchell, MD, both MAHEC graduates, are the last to join the group. When they take their seats, they come full circle in more ways than one.

Learning to Treat People Not Patients

Dr. Peverall came to Celo Health Center more than 21 years ago as a MAHEC rural fellow. Originally from New York, she met and married a North Carolina native while in medical school. When it came time to choose a residency program, she looked nationwide. MAHEC's family medicine residency program in Asheville was her top choice because of its location and reputation for providing excellent hands-on training and patient care.

Elizabeth's rural fellowship showed her the real promise of family medicine. During her fellowship year, she learned how to treat people not patients and to support neighbors not strangers. Celo's small mountain community quickly felt like home.

More than two decades later, it still does.

When asked what has been the most rewarding aspect of her rural career, Dr. Peverall doesn't hesitate.

"The same thing that makes it the most challenging: how well you get to know people," she explains. "You see your patients at baseball games, in the grocery store, at church, and at your children's school. Sometimes it can be a little overwhelming."

"At the same time, you get to see what affects people's health outside your office. You get to take care of the whole person and their family," Elizabeth notes. "You get to do more than treat strep throat or serve as a switchboard operator for a lot of specialists. You get to practice the full scope of family medicine."

This broad skill set is something Dr. Peverall now shares with a variety of learners that include medical students, residents, fellows and other health professions such as nursing, pharmacy, and behavioral health.

"Being a teaching site keeps us on our toes," Elizabeth smiles. "You can't just pretend to know the things you are teaching. You have to really know them and be willing to take the time to ensure your students acquire the skills they need."

Practice Makes Perfect

When MAHEC approached Mountain Community Health Partnership about becoming a rural teaching practice, Dr. White - one of Celo's newest providers - was eager to get involved. In fact, she was the faculty champion for this initiative.

"It was largely selfish," Jessica jokes. "I missed the ongoing learning opportunities MAHEC provides and being able to contact faculty whenever I had questions. I knew that creating a culture of continuing education would make rural practice more sustainable for me in the long term."

"There are a lot of unknowns when starting out in rural practice," she explains. "Things you can't anticipate in advance. My rural training helped me develop my skill set to meet unexpected needs."

In Jessica's case, these needs included access to medication for opioid use disorder and hepatitis C treatment, two services she helped establish at Celo Health Center. An ongoing connection to UNC Health Sciences at MAHEC will be invaluable as she looks for new ways to improve care such as integrating clinical pharmacy services, which is the topic of today's didactic.

MAHEC's rural teaching model is designed to ensure practices are well-connected to academic resources that include weekly practice-wide didactics, mentoring, and faculty development. Rural teaching practices also receive administrative support to transform workflows to accommodate learners from a variety of health disciplines. This approach ensures learners receive the multidisciplinary team-based training that is essential for meeting a wide range of rural health needs.

Limited resources present a challenge for many rural providers, something Jessica's colleague Patricia Hall discovered when she joined Celo Health Center last year.

"I have to take full responsibility for my patients," she shares. "There are no easy referrals in a rural practice. If I recommend a specialist, I have be sure that it's worth all of the resources my patient may have to pull together to make it possible."

"You can't just rely on protocols," Patricia explains. "I often ask myself, 'if this was my family member, would I try to talk them into doing this?'" She weighs her answer alongside factors like lack of insurance and financial resources to ensure she isn't recommending unnecessary procedures or compromising her patient's care. Some days, it's a tricky balancing act. Figuring out how to do it well can be an act of social justice.

It was social justice that inspired Patricia to pursue a career in rural medicine. She attended Berea College, which is well-known for its social justice mission, and took her first step toward a rural health career. After graduating from medical school, Patricia's journey took her to MAHEC's rural family medicine residency program in Hendersonville, then a rural fellowship, and now its first rural teaching practice.

Because she's chosen this path, Patricia is developing a broader skill set than many of her more urban-centered colleagues. She's also developing as a community leader, a role rural physicians are frequently called upon to fill. One way Dr. Hall is answering this call is by helping to mentor the next generation of rural health providers.

Following the Call to Serve

First-year medical student Kacey Scott has spent the first half of her summer interning with Patricia.

"I'm enjoying learning from Dr. Hall," Kacey explains. "She is flexible and integrates me into her practice. I've gotten a lot of great hands-on experience working with her patients, which is really helpful at this point in my education."

Kacey is a UNC Asheville graduate and former MAHEC librarian who was embedded in MAHEC's Department of Obstetrics and Gynecology. Through this work, she learned that women in Western North Carolina often have to travel long distances to get basic prenatal care.

"At some point, it sunk in that people could train and practice where women live so they don't have to travel so far to get care," Kacey explains. "I realized I could fill that role. I'd always loved medicine, and I was developing a passion for women's health."

Kacey developed another passion while at MAHEC, and it came as somewhat of a surprise.

"I never saw myself going into academic medicine," she confesses. "But I had the opportunity to shadow a lot of wonderful physicians and saw how they interacted with their patients and with learners."

"At MAHEC, compassion flows from the faculty to the residents and other learners," she explains. "When these providers graduate, that compassion pours out into the community. It's awesome, and it makes me want to take on learners so I can pay it forward."

Kacey currently has her sights set on practicing medicine in Jackson County where she believes her language skills could support the community's Spanish-speaking population. If she does, she could end up working at a MAHEC rural teaching practice.

Mapping the Roads to Rural Practice

Back in Asheville, Bryan Hodge, DO, looks over a large map of Western North Carolina that identifies counties with the greatest healthcare needs. Yancey and Mitchell stand out as do Jackson and hot spots like Cherokee and Swain.

Although the entire region is experiencing healthcare workforce shortages, a number of WNC counties have notably worse primary care, dental, and mental health outcomes. This is where Bryan and his team are putting most of their focus.

Dr. Hodge is the program director for Rural Health Initiatives at UNC Health Scieces at MAHEC. He's also a rural family physician and a national rural health consultant for the American Academy of Family Physicians. Over the past year, he and his team have been working on establishing rural teaching practices across the region and a new rural family medicine residency program in Watauga County in the northwestern corner of the state.

"If there's one high impact thing you can do to actually change the health of a rural community, it would be to send a family physician into that area," Bryan shares.

With that in mind, Dr. Hodge and his team have identified potential practice sites where there is high need but also opportunities to partner with established primary care practices and rural hospitals.

So far, their efforts are paying off.

The rural teaching practice in Yancey and Mitchell counties has successfully completed its first year has supporting a variety of learners from high school students to rural fellows. MAHEC opened a second rural teaching practice in August in Polk County in partnership with St. Luke's Hospital, Foothills Medical Associates, and Isothermal Community College. MAHEC is partnering with Blue Ridge Health to establish a third rural teaching practice at its federally qualified health center in Haywood County. And MAHEC's strong partnership with Cherokee Indian Hospital makes it likely that a rural teaching practice will be developed in Swain County in the near future.

"MAHEC was established forty-five years ago as part of a statewide effort to address healthcare workforce shortages particularly in more rural areas," explains MAHEC CEO Jeff Heck, MD. "Over the last several years, North Carolina has given us additional resources to support our efforts to expand the rural healthcare workforce."

"We take our mandate seriously," he adds. "Our success has the potential to extend well beyond our region. As we transform health in Western North Carolina, UNC Health Sciences at MAHEC is creating a blueprint for rural communities across the nation."

Those who are building roads to rural health careers here in WNC are hopeful they will soon become well-traveled.