At just 5 weeks old, Waylon Williams is a trailblazer. He’s the first baby born in Primary Care Centers of Eastern Kentucky’s new women’s residential center. The facility, called Beacons of Hope, offers temporary housing for women confronting substance use disorder.
That recovery housing for women is available in a rural, financially challenged community is noteworthy. That it’s available for women with babies is remarkable. Equally so is the fact that Primary Care Centers of Eastern Kentucky (PCCEK) is a rural health clinic (RHC), and recovery housing is not among the services rural health clinics typically offer. A men’s residential center is soon to open.
Beacons of Hope is an extension of PCCEK’s Pregnancy & Beyond, an addiction-treatment program that offers obstetrical services, medication for substance use disorder, prenatal education, pediatrics, and counseling – services that in so many rural communities nationwide are in critically short supply or entirely absent.
The town of Hazard, where the largest of PCCEK’s four clinics is located, is in Perry County. Perry County ranks 117th among Kentucky’s 120 counties in health outcomes. Life expectancy is 67, as compared with 78.5 for the country.
Addressing such challenges requires the full force of a health care ecosystem that includes hospitals, clinics, private practices, public health agencies, and a range of support services. Rural health clinics play a critical role in this ecosystem. “They’re an important part of the primary care landscape,” said John Gale of the Maine Rural Health Research Center.
RHCs are safety net providers whose original mandate was primarily to increase access to care for those on Medicaid or Medicare. They provided primary care and perhaps a few other services. But the Rural Health Clinic program has evolved over the years, and some clinics, like Primary Care Centers of Eastern Kentucky, have expanded their roles quite considerably.
Among the health care services, PCCEK offers are dentistry, a diabetes center, a women’s health center, extensive radiology and imaging, a range of behavioral health services, a pharmacy, and a hospice care center. It offers a sliding scale for fees.
PCCEK has nurses in each school in the county system. It has an event space where it hosts maternity fairs and Easter, Halloween, and Christmas gatherings, and which in the wake of the region’s catastrophic flooding last July served as a distribution center for food and supplies.
And with such a wide array of services, CEO Barry Martin contends, PCCEK is addressing arguably the greatest challenge to rural health care: a shortage of health care professionals.
Gale said the projection is that there’ll be a shortage of 50,000 or more primary care providers nationwide by 2032, and that the majority of those available aren’t likely to want to practice in rural areas.
It’s taken some time, Martin said, to impress upon newly minted health care professionals that Perry County is a promising place to build a career, but his message appears to be resonating. He’s especially focused on enticing young people from the region to head back home and hang a shingle at PCCEK.
“Come back here,” Martin urges them. “Look at what we’ve built. It’s not a double-wide on the side of the road.”
Meeting Needs, Steady Growth
The Rural Health Clinic program was launched in 1977 as a Carter administration initiative. The impetus was to make it more viable for rural providers to stay in business with a relatively heavy load of Medicaid and Medicare recipients and few patients with private insurance by offering higher reimbursement for those federal programs.
RHCs must be in a health professional shortage area. They must take a team approach to care: physicians working with a staff of nurse practitioners, physician assistants, certified nurse midwives, and others.
The number of RHCs has grown significantly over the past decade or so. In 2010, there were fewer than 4,000; today, there are 5,270. They’re in every state except Alaska.
RHCs differ from federally qualified health clinics (FQHC) in that FQHCs can’t be for-profit providers and must be governed by a board of directors of which the majority of members must be patients of the clinic and demographically representative of the community. FQHCs must offer primary care and preventive and enabling (such as case management and transportation) services. In meeting these stipulations, they receive higher reimbursement from the federal government.
PCCEK is a for-profit entity. It launched in October of 2003 in a 6,700-square-foot facility with 15 employees offering family medicine, pediatrics, simple X-rays, ultrasounds, and a lab. In 2008, it expanded into a 30,000-square-foot building, and in 2015 into its present Hazard location, a 60,000-square-foot complex, formerly a Kmart. It also has clinics in the nearby towns of Hindman, Hyden, and Vicco.
More than 39,000 unique patients came through PCCEK’s doors last year, Martin said, for a total of 180,000 encounters. The clinic employs more than 400 people.
‘Ease a Little Bit of the Burden’
“I like to say that we provide services from the head to the toe and the womb to the tomb,” Martin said. “And that is true.”
Care for diabetics is an urgent need in this region. In 2021, Kentucky had the sixth highest diabetes death rate in the country. The Kentucky Department for Public Health reports that between 2000 and 2018, the number of diabetes diagnoses had doubled. Perry County has among the highest incidence rates in the state.
PCCEK operates the Mary E. Martin Diabetes Center for Excellent (named in honor of Martin’s mother). It’s the only diabetes facility affiliated with the University of Kentucky’s Barnstable Brown Diabetes Center. It offers comprehensive case management.
“We try to ease a little bit of the burden,” said Martha Bailey, a registered nurse and licensed diabetic educator from nearby Letcher County. “We’re doing preventive maintenance. We’re talking to them about their diabetes.”
Before PCCEK opened its diabetes center, people routinely drove 250 miles roundtrip to Lexington to see a doctor. Many simply went unexamined, undiagnosed.
“They may come in here and have an ulcer they didn’t even know they had,” Bailey said. “We’ve had patients come in that had tacks in their feet. They didn’t know it until we did the exam.”
PCCEK is the only place in Eastern Kentucky offering pedicures specifically for diabetics. “When they do the foot care here,” she said, “That’s their time to be pampered.”
The center also provides $10 vouchers for the local farmers’ market. “With the people on fixed incomes, that helps them eat a little bit healthier,” Martin said.
Immersion in a Community
John Jones serves as PCCEK’s medical director and oversees the diabetes center and Beacons of Hope. He’s a Hazard native, and while he believes that being homegrown certainly helps in most effectively reaching his patients – “We just know each other. The trust is there.” – he hastens to add that trust can likewise be built in those who come from elsewhere, assuming you’re willing to make yourself known in the community.
“I think it’s a little different than the stereotype,” Jones said. “They’ll accept you with open arms. It’s just about being out there.”
Trust was of the essence after the July flooding. Jones tells of a father, mother, and daughter who were swept from their home, strapped themselves to a power pole, and hung on. The family now lives with relatives.
When it rains, Jones said, the child is terrified; she has nightmares and flashbacks. When he talks to the dad about exploring counseling, “I think he doesn’t hear that from me as a doctor; he hears it from me as a friend.”
Dealing with such issues – or dealing, on a day-to-day basis, with a patient who’s homeless with no way to refrigerate their insulin, or one with no transportation to make an appointment – such things aren’t taught in medical school. You learn through immersion in a community.
Martin trusts he’s creating an environment that will draw young professionals into his community.
A Continuum of Care
Nathan Baugh, executive director of the National Association of Rural Health Clinics, believes the RHC program isn’t well understood among decision-makers in Washington. FQHCs, he suggests, get more attention and are thus more likely to receive grant funding and be recipients of favorable policy decisions.
“It’s been a long-term struggle for us,” Baugh said, though he feels some progress has been made in the pandemic, with the two programs being treated more equitably for federal allocations and resources. “We were happy to see that. But we still have a massive granting and understanding deficit relative to the FQHC program.”
In Eastern Kentucky, Barry Martin believes the benefits of a comprehensive rural health clinic to a region and state are clear. Nearly 200,000 annual health care visits speaks volumes. Moreover, “The governor is looking for people like us to help develop a second-chance workforce,” Martin said, “and that’s what we’ll be doing with Beacons of Hope.”
The big-picture objective for all stakeholders is a continuum of care: health, housing, employment, well-being.
“I got lucky,” Brittany Williams said of finding a temporary home at Beacons of Hope for herself and her son Waylon. “They’ve taught me self-control,” she said, “and structure. They’ve helped me structure my life.” She’s hopeful about the future.