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Podcast: CU-Led Playbook Gives Rural Health Leaders a Voice

Report empowers leaders to solve own challenges, engages policymakers on problems in rural America

minute read

Written by Chris Casey on March 15, 2021
What You Need To Know

When the pandemic struck last spring, rural health experts at CU and the Colorado Hospital Association fanned out across the state to ask rural healthcare leaders what was working and what wasn’t amid the public health crisis. Their work resulted in a 134-page playbook that is getting rave reviews from healthcare leaders and policymakers nationwide.

Lauren S. Hughes, MD, MPH, MSc, FAAFP, and Benjamin D. Anderson, MBA, MHCDS, have dedicated their careers to transforming rural healthcare in America. When the nation and already hard-hit rural healthcare systems plunged into the throes of the COVID-19 pandemic last March, they sprang into action.

“We realized we really needed a playbook in an environment where a playbook is impossible,’” said Anderson, vice president of Rural Health and Hospitals for the Colorado Hospital Association. “We need a roadmap toward how to navigate something like this – a capacity-building tool for rural communities.”

Hughes is the state policy director of the Eugene S. Farley, Jr. Health Policy Center at the University of Colorado School of Medicine and previous deputy secretary for health innovation in the Pennsylvania Department of Health, while Anderson has 20 years of experience in healthcare and nonprofit administration.

Although they each have strong backgrounds in rural healthcare and policy, Hughes and Anderson knew the playbook should be in the voices of the people working on the front lines.


Hughes had the idea to craft the playbook, “Re-imagining Leadership: A Pathway for Rural Health to Thrive in a COVID-19 World,” in a case-study narrative, creating fictional characters and stories from actual conversations with over 30 rural healthcare leaders in Colorado. The team – Hughes and Anderson led a group of nine authors – conducted the interviews early in the pandemic and, by fall, were putting the finishing touches on the 134-page report.

Getting national attention

It’s already been released to 1,100 hospitals through the American Hospital Association, and officials at the Bipartisan Policy Center in Washington, D.C., were so struck by the findings that they’ve requested a meeting with the authors.

“The playbook is really designed to teach the users of it how to own their own challenges and how to engage in the problem-solving process creatively and together as a team,” Hughes said. “We really valued that approach because it respects the substantial expertise these rural healthcare leaders already have and bring to the table.”

Anderson said the leaders who shared their pandemic struggles deserve ample credit. “They … shared their vulnerabilities in one of the most vulnerable times in their lives – to say, ‘These are the things we’re learning and things we still don’t know. Can you help us …?’”

Hughes and Anderson can each point to many career highlights, but they both rank the “Pathway for Rural Health to Thrive” as one of their most meaningful projects.

Health equity discussion

“It is a practical move to include rural America in the health equity discussion,” Anderson said. “These are tools that can empower rural healthcare delivery leaders to step forward and solve their own problems, and it’s also been a very important tool to engage people in Washington around the issues facing rural America.”

Hughes agreed, saying she’s “forever hooked” on the capacity-building approach. “At the end of the day, it’s about seeing and hearing and valuing the people … how can I be a part of actually helping you be stronger, better, more effective.”


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Read the full transcript:

Disclaimer: Transcripts are generated using a combination of speech recognition software and human transcribers. It may contain minor differences from the audio, including some edits for clarity in print. Please check the recording and with the Communications team before quoting. 


Chris Casey Welcome to CU Anschutz 360, a podcast about the CU Anschutz Medical Campus. We feature faculty, staff, and students, and their interesting and innovative work. My name is Chris Casey, and I'm the Director of Digital Storytelling here in the Office of Communications. Today I have the pleasure of speaking with Lauren Hughes and Benjamin Anderson, both nationally recognized leaders in transforming rural healthcare. Dr. Hughes is an Associate Professor of Family Medicine in the CU School of Medicine and the State Policy Director of the Farley Health Policy Center. Dr. Hughes previously served as Deputy Secretary for Health Innovation in the Pennsylvania Department of Health, where she launched the Pennsylvania rural health model. Her research interests include rural health, primary care, and public health alignments.

Benjamin Anderson is the Vice President of Rural Health and Hospitals for the Colorado Hospital Association. He has 20 years of experience in healthcare and nonprofit administration and provides leadership and direction in the development and execution of the CHA's rural strategies. He also advocates on behalf of rural hospitals and health systems. Welcome Lauren and Benjamin, and thank you for being here today.

Benjamin Anderson Thanks for having us.

Lauren Hughes Thank you.

Chris Casey The two of you are the lead authors of the recently published playbook called Pathway for Rural Health to Thrive in a COVID-19 World. This playbook must've been quite an undertaking. Over 30 Colorado rural healthcare leaders interviewed resulting in a 115 page report. So I'm curious what prompted this effort and how did you go about getting it launched so quickly?

Benjamin Anderson I'll take that one. I remember it was in April of 2020 and amidst the first surge, and we were all really pushing hard trying to figure out how to make sure that healthcare delivery would remain sustainable, that healthcare workers were protected, that they would have the protection they needed to come to work, and that we'd be able to deal with a pandemic that we knew so little about. We want to help, what can we do? How can we engage? And what came out of that conversation was we really need a playbook in an environment where a playbook is impossible and we need a roadmap toward how to navigate something like this, a capacity building tool for rural communities.

Chris Casey Basically, the backdrop of the playbook is the pandemic made the situation for rural clinics very challenging. And let's face it, they've been in kind of a public emergency situation for some time. Is that not the case? Could you expand on just the situation in rural healthcare prior to the pandemic?

Lauren Hughes Absolutely. No, it's an excellent question, Chris. And the reality is that there have been a variety of different types of crises in rural communities and rural healthcare for a number of years, and the pandemic certainly has ripped off that bandaid, for lack of better words, in terms of exactly how many challenges the rural communities have. Coming into COVID-19, there were two predominant public health emergencies from my vantage point. And the first is around poor maternal health outcomes for moms and for babies and maternity care deserts or challenges in access to needed maternity care services in rural America, as well as the opioid crisis. That opioid crisis has not gone away and neither have the associated increases in HIV or hepatitis B and C that have gone along with the opioid epidemic. Both of those are still there under the surface while we have necessarily turned our attention to mitigating and containing and responding to COVID-19.

I'm also concerned about emergencies that are looming, and I think there's two that have become even more accentuated during COVID-19. The first is around the mental health burden related to isolation and school closures and the impact of those on our kids in rural communities, as well as the digital divide. If anything, over 2020, we have seen that broadband access really has become viewed as a public utility and a public good. We've used it for remote work if that's been possible for families, we've used it for education, accessing goods, staying in contact with friends and family. That is something we certainly need to mitigate and fix moving forward.

And then lastly, it's also important to keep in mind that there've been a lot of economic crises related to rural healthcare in our communities over a number of years. Since 2010 alone, 135 rural hospitals have closed their doors. This is not just then becomes a challenge for access to healthcare services, but rural hospitals are significant economic drivers and engines in those rural communities. They produce a number of high quality, high paying jobs, but they also are an opportunity to attract other businesses to those communities. And so when those hospitals close, it's a significant challenge.

And it's also important to keep in mind that in rural America, the recovery from the Great Recession of '07 to '09 has not been even or equitable across the country from one rural area to another and certainly between rural and urban areas. And our rural residents are more likely to be uninsured and also are more likely to have significant medical debt if they encounter an emergency of some sort. There are many more, but those are the key ones that I think about that really shape our approach to assisting and helping rural communities thrive moving forward.

Chris Casey So when the initial shutdown orders came out regarding the pandemic last March, April, I imagined that there might've been some ruffled feathers maybe in rural communities feeling as though that these orders were kind of delivered for a one size fits all type approach to the emerging public health crisis. Was that something that came into play and were there any other surprises that you guys gleaned from your interviews with the rural health providers as this was just starting to evolve last spring?

Benjamin Anderson Yeah, great question, Chris. COVID-19, as Dr. Hughes said, shined a light on the disparities that existed in rural communities in terms of their healthcare delivery. Things that we knew were going on but were a bit under the surface prior to that became obvious and impossible to ignore when the pandemic arrived. The challenges that really emerged right out of the gate were around staffing, around allocation of space, access to supplies, spending, or finance. Those are the things we were focusing on really as a state response effort right out of the gate and those were the things that we were communicating to lawmakers as well as they were making decisions.

As we had these interviews with our key informants around the state, we uncovered some other common challenges too. And among them are the need for community engagement, challenges around that, crisis communications, cross-system collaboration, how to coordinate testing and screening in their response efforts as well. And so we uncovered more common challenges and we work those into the contents of the playbook.

Lauren Hughes Chris, I'd like to add to that, especially around the one size fits all approach. As you mentioned in my bio, I came to CU from a governmental public health role, and certainly appreciate that tension between efficient public health orders, especially in an emerging crisis that we didn't know all the details of and didn't have full information, versus effective or inclusive policy making to have all the right voices around the table. So I fully recognize that tension and I have been there myself in terms of having to make those kinds of decisions. But as time went on last year, we did learn more information about how this infection has spread, right? And that information could certainly have been turned into ways to nuance those public health orders and take into consideration the local transmission dynamics in rural and smaller communities.

One of my favorite research studies came out last summer by Dr. David Peters, who is a rural sociologist at Iowa State University, and he was studying the different factors that render certain geographic locales more or less vulnerable or susceptible to COVID-19. Clearly in large cities, Denver, New York City, LA, Chicago, what have you, population density was the driving factor for the rate of spread in those places. So when you think about shelter-in-place or stay-at-home orders or business, school closures, mask orders, these sorts of things, those kinds of policies really make sense if that is your underlying driving factor to increase susceptibility in those communities.

On the other end, when you get to micropolitan, which is defined as at least 10,000 individuals, but less than 50,000, then semi-rural and rural, the drivers of infection change dramatically. In micropolitan communities a major driver of infections are meat and poultry processing plants. In semi-rural, that is more so your colleges, prisons, military barracks. So kind of those group quarter types of situations. And in rural communities, the largest two drivers of COVID-19 infection rates that we have seen have been the population over 65 years of age and those that are living in nursing homes. So when you think about micropolitan, semi-rural, and rural communities, the drivers of infection are quite distinct compared to large urban settings.

So we have now a year exactly to when COVID arrived here in Colorado. We have the benefit of hindsight, but moving forward, we can apply that knowledge that in rural communities, maybe instead of a one size fits all, we're going to close businesses, shelter-in-place types of orders, stay-at-home orders is that we need to identify, isolate, and protect those vulnerable pockets of communities that we know are more likely to accelerate the rate of infection. So, again, lessons learned in hindsight that we can apply moving forward.

Chris Casey Great, great. And this next question pertains to that looking forward aspect as well. So I'm curious if any of the forced changes that occurred in rural healthcare during the pandemic year, if any of those changes came out for the better going forward. In other words, was something learned through this public health crisis in the rural settings that helps inform those professionals and those administrators going forward?

Benjamin Anderson Hey, Chris, I love that question. Yes. The answer is yes. So I sometimes like to say that COVID shoved us into doing the right thing. It really pushed us to new limits and with that capacities were built within rural systems and within urban systems. It pushed us to do things we didn't know we could do and it also pushed us to do things together that we didn't know we could do together. And one of my favorite examples is a combined hospital transfer center. A group of hospitals got together around the state and agreed that we were going to find a way to make sure that every patient that needed to be admitted for COVID-19 or otherwise would be admitted.

We developed a buddy system where every rural hospital had an urban hospital buddy that would guarantee they would take their transfer or admission if they needed to, but it came with some parameters. It came with some guardrails, and that was our covenant, so to speak, or a commitment that if that urban hospital was able. Or there was a need to transfer that patient back to rural communities, that that rural community would promise to repatriate the patient. Or in certain scenarios, when urban systems became overwhelmed, we were able to transfer urban patients out to rural Colorado hospitals to utilize their capacity and receive optimal care in those situations.

And so what was or had traditionally been a one-way road, one-way transfer road from rural into urban systems was widened through COVID-19 into a two-way road. And that two-way road now remains and we believe that will remain in place. And also the relationships that have been established between healthcare leaders, between public health leaders and primary care leaders or physician leaders and hospital leaders, those relationships that are established and with a new understanding of the capabilities of each component of our overall healthcare delivery system, those will remain in place. And those are really exciting.

Chris Casey So kind of forcing a more holistic almost patient care experience out there.

Benjamin Anderson I believe it permanently changed, Chris, the relationship or that dynamic between rural healthcare delivery systems and urban healthcare delivery systems. They learned to rely on each other in crisis in new and more innovative ways. I think the relationships were established already going into COVID and were only strengthened between primary care practices and public health departments and hospitals as well.

Lauren Hughes And I agree with that, Ben. And I think to that point, not only are those relationships established that can be a model for how you collaborate across systems and solving problems moving forward, but that at the very basic level, there is an appreciation now for how connected we are, rural-urban. And let's not talk about it as a rural-urban divide. Let's talk about the rural-urban continuum, right? We are connected. We need each other. And what happens in rural America impacts urban America and vice versa. So perhaps it's time that we start working together on tackling tough challenges that we face.

Chris Casey So my next question pertains a bit to just how you put the playbook together, and that is as a writer and editor here on the CU Anschutz Campus, I find it interesting how stories get put together. And here you've crafted a playbook which is a long running narrative in a way, you've turned it into stories which I found was an interesting way to convey the information in an interesting way. I'm curious why you chose to take the information you gleaned and turn these into like fictional case studies. You have like a fictional town in the Midwest, a fictional town in the West because I was starting to Google these towns and I couldn't find them. And then I realized they don't exist.

Lauren Hughes You found that they don't exist.

Chris Casey So could you just tell me what went into the thought process of doing it that way?

Benjamin Anderson Thanks, Chris. So they don't exist, but they very much do exist. And that's the interesting dynamic with this playbook. So I remember Lauren calling me after she'd been out on the road doing some interviews. We tag team these interviews over the course of several months, and she called and said, "I think we just uncovered a goldmine." She had met with a few rural hospital leaders in the mountains and had come back with an idea that really ended up defining how this playbook was structured. And one of them held up the book Five Dysfunctions of a Team by Patrick Lencioni, which is a leadership parable. And he said, "If you want this thing to be helpful to us, you will design it in a way that we can see ourselves in it and we can learn to solve our own problems through it." And that's really how that book is structured.

And what we came back with was, well, this is great. Lauren's a brilliant researcher and I probably naturally lean towards storytelling. And so we realized that we could partner on something like this. That we could take what we learned and some actual stories from these interviews and pull them together into a pair of cases that are fictional, but as our rural leaders are reading them, they're saying, "Yeah, and that piece actually literally happened in our town. I can relate with this." And so in there, there's some juicy details. There's the tourist-

Chris Casey Yeah, that's why I thought so. Yeah.

Benjamin Anderson Yeah, the tourist that shows up-

Lauren Hughes - And they represent reality.

Benjamin Anderson They do. The tourist that shows up with fishnet pantyhose over his head because he's protesting that's his mask and he's not going to wear a real mask. And people that are scared because they won't have the right protective equipment. And fortunately we were able to plan some efforts in the state that got people the PPE they needed, but these were early fears that people didn't know about. And so, yeah, those things were weaved into there, but the intent with it was that people could see themselves in the story and through solving the problems and the cases they were solving their own as well.

Chris Casey Well, I thought it was a very effective approach. And I could see... Yeah, I'm sure that your audience, especially some of those administrators in the rural areas, yeah, very much saw parallels to their very daily existence in the report.

Benjamin Anderson I think Lauren used the term ‘anecdata.’

Lauren Hughes That's right.

Benjamin Anderson We needed the anecdotal stories and we needed the data to back it up.

Lauren Hughes The data. Hashtag ‘anecdata.’

Benjamin Anderson So we made a pretty fun partnership in that.

Chris Casey A theme running through the case studies is a general lack of resources, which you both touched on a fair amount so far, including being at the end of the supply chain, declining clinic profitability due to lower inpatient volumes, and the demographic shifts occurring out there. Could you talk about just this lack of resource problem a bit more, and also just the very daily struggle, I would imagine, in rural healthcare of recruiting and retaining quality folks, that aspect? Could you expound on those issues?

Lauren Hughes Yeah, absolutely, Chris. So, as we've mentioned before, the pandemic certainly has shone a bright light on the very real fractures and deep fractures that exist in our rural healthcare delivery systems here in Colorado and nationwide. In addition, the pandemic has also shone a bright light on similar fractures in rural primary care practices, in rural public health departments, and most certainly in our social sector safety net systems in rural communities, all for we're not particularly robust entering COVID-19 and are even struggling more now. And I think if anything that, in terms of everything from recruiting and retaining needed healthcare workers and professionals, getting needed supplies, being financially sound, the pandemic has also demonstrated that for volume sensitive entities, in particular, rural hospitals and rural primary care practices, that when that volume spigot was suddenly turned off in March, April, May last year, the ceasing of elective procedures, most rural hospitals in Colorado elected to stop those temporarily to mitigate the spread of disease.

When you think about primary care practices, they were saying, "If you don't really need to come in, just wait on this visit until we get a handle on this." We were able to see that those two entities really have struggled financially as a result. So it begs the question, do we need to think about different payment delivery models for rural hospitals and rural primary care moving forward that aren't so contingent upon the volume of services rendered in those facilities, especially from a primary care lens? My colleagues at the Larry Green Center have now conducted over 25 surveys of primary care practices to understand how they have fared. This is the longest running survey. It started in mid-March last year. It has now been going for almost a year. And it's a treasure trove of information that helps us understand how primary care is fairing, particularly in rural communities.

You certainly have the financial worries, but then our primary care practices are also reporting that they're suffering from very real and substantial burnout and the stress of keeping their practices afloat and making sure that their staff members get a paycheck, right? To keep food on the tables for their families and lights on and all of those things that we need to do. Illness, many of the responses to the survey have been ill themselves or have been exposed to COVID-19, worrying about bringing it home to their families, delayed grief for loss of practice members or patients and not able to grieve together as a practice family, and misinformation. These are some real themes that our primary care practices have been dealing with over the past year.

And I think moving forward, coming out of this, I worry about shadow pandemics that we need to start planning for and addressing immediately. And as we've talked about before, the worsening mental health burden, particularly among our seniors in rural communities, thinking about isolation and not being able to be in contact physically with their families, behavioral health concerns for our children with school closures, and then on the medical front in terms of delayed preventive care and the worsening burden of chronic disease and those manifestations. So we've been through a challenging year and we have some real profound challenges that are already beginning to manifest themselves now.

Benjamin Anderson I think I would add a little bit to that. That was a great summary of what's going on from Dr. Hughes. What we're hearing more and more from our healthcare workers is that burnout is being treated as an individual issue. Here's a breathing exercise resource or course.

Lauren Hughes A meditation app.

Benjamin Anderson Yeah. Here is a mindfulness class. Those efforts while valid and well-intended by systems, don't necessarily account for the systemic or structural issues that are driving burnout. And one of them shared with me this mindfulness class, I'm sure they mean well, but that doesn't fix my call schedule. And breathing classes don't necessarily fix a dysfunctional culture or a culture that lacks accountability or the work hours, the overtime, things like that, those things, they're individual coping mechanisms that are really important to navigate this and there's really an important need for transformational leadership thinking to address some of the structural stuff. And I do believe we have the capability of solving some of these problems if we're willing to think about them differently, but we shouldn't overlook the structural issues driving burnout.

Chris Casey That's interesting. Yeah, because, right, you do tend to hear about that more in isolation just person to person, like things... Yeah, practices they can do on their own kind of thing.

Lauren Hughes Absolutely. And the more that we are impacted by this, particularly the impact of this from a burnout and a mental health standpoint for our healthcare workforce, rural or urban both will be felt for years after this. When more people step forward and say, "I'm struggling with this or I'm struggling with that," it's not an individual issue. It's a systemic issue that we need to really address and change policies to help these healthcare workers.

Benjamin Anderson It is absolutely true. This is obviously something Dr. Hughes and I are both very passionate about it's to hand someone a breathing exercise as a solution to burnout is the equivalent of saying to someone who is homeless or chronically ill, "If you would just eat more vegetables and walk more, you'd feel better," without recognition that that person doesn't have access to fresh vegetables or safe places to exercise or walk. We've got to acknowledge that there are individual decisions and boundaries that we can set in places as people that can help us and that there are also some things we can do together.

Chris Casey I'm curious about the rise of telehealth during the pandemic, whether that aspect promises perhaps more efficient and effective healthcare delivery in rural settings, or are perhaps rural providers not adequately resourced, reimbursed say, by insurance for these kinds of telehealth services?

Benjamin Anderson Great question, Chris. This is a good one and certainly relevant right now. We've seen more advancements in telehealth in the last year than we saw in the previous 20. We did the work of five or 10 years at least of advancements.

Lauren Hughes And sometimes within 72 hours.

Benjamin Anderson Yes, sometimes within just days. And again, COVID shoved us into doing the right thing. What I'd say about telehealth, and it's touted at a federal level and by funders and by policymakers, is sometimes as the cure all for rural health, what they need is broadband and they need access to these urban providers out in rural areas. And I'm not convinced that's quite it. I think -

Lauren Hughes [crosstalk] - Neither am I. 

Benjamin Anderson We've got an important responsibility to make sure that every American has access to broadband. That is a public utility. We should not have a situation where a third of America is struggling with that. So that's really important. It's crucial. But I would say that any virtual care intervention that overlooks the sacred relationship between a primary care doctor in a rural area and their patients will probably not work, but any virtual care intervention that leverages and reinforces the sacred relationship between rural primary care providers, not just doctors, but PAs, nurse practitioners, and others, those will likely go because the primary care provider is the gateway. Holds the keys to the healthcare kingdom, so to speak. And if they feel reinforced by the resources that can come from more urban areas through technology, they feel reinforced. We will build the capacities of our primary care workforce out in rural areas and we'll see it really fly.

Lauren Hughes Exactly. I think access to virtual support is an incredible adjunct both for patients and for the providers alike, right? For patients, there are often significant reasons why people choose to live in rural or frontier communities, right? They want to be there, right? But sometimes they do have higher level care needs that may require expertise or consultation from larger systems that they don't have access to or need more frequently than what might be rotating cardiologists, for example, that might come to the rural community once or twice a month or something like this. And so it's an opportunity to provide care locally for those patients in concert with their primary care team, and then those patients and their families don't have to travel to the larger city.

But to Ben's point, it also is a way to support and to shore up those primary care teams in those rural and frontier communities so that they have access to ongoing training and knowledge and maybe remote monitoring, et cetera, in those larger urban or suburban centers that can be of great support to them. And to our earlier point in talking about burnout, so that they don't feel like they're out there all by themselves. That they have colleagues that they can call and talk to and be supported. And both of those, those services for providers and for patients will be much more successful if you have robust access to broadband.

Chris Casey A big aspect of the playbook you created was developing a rural-focused healthcare delivery system assessment tool. A tool that folks can refer to to just help them navigate their daily struggles. And you talk about five domains impacting efficiency and effectiveness in a public health emergency. So can you outline those, perhaps those five domains and how they can be strengthened?

Lauren Hughes Absolutely. Yeah, I think for Ben and for me, one of the aspects that we're perhaps the most excited about as it relates to the playbook is in fact this assessment tool. And we developed it because there was a significant need for something like this. We looked at many different assessment tools and found that quite frankly, many of them were too narrowly focused on one particular subject. So they may offer an organization the opportunity to assess their readiness for telehealth, but that gives you insight into one particular aspect of healthcare delivery. On the other hand, many assessment tools that exist are really built for urban and suburban systems. They don't respect or understand or take into consideration the scope and scale and context of rural healthcare. And through our analysis, we ultimately developed this assessment tool designed for rural hospitals and for rural primary care practices along five domains.

And those domains are governance and leadership, community engagement, financial health, clinical care, and emergency preparedness and resilience. And we selected these five because they're not only useful for understanding an organization's capacity to respond to a public health emergency, but they also... Those are five critical domains that provide insight and perspective into the overall health of a rural hospital primary care clinic in non-emergency times. So I'll take a couple of these as an example and how they could be strengthened.

And so governance and leadership for example. A large focus of the work that's important to Ben and to me and that we believe will be really critical for improving rural healthcare systems moving forward is to really focus on building transformational leadership capacity within rural hospitals and primary care practices. In terms of community engagement, really engaging community members and other organizations as equal partners in problem solving moving forward. Lastly, around the financial health dimension, especially building on the lessons we've learned in COVID-19, how can we reconceptualize our approach to really investing in rural healthcare in ways that may not be so contingent upon volume of services rendered because rural doesn't have the volume for a whole variety of very legitimate reasons compared to their urban counterparts? So how do we... Those are big questions, but they are doable. They are challenges that we can take on.

Chris Casey Now that we're in the vaccination phase of the pandemic, are there any rural specific issues related to vaccines and distribution and just general acceptance out there that you've come across?

Benjamin Anderson Yeah, the vaccine has been a challenging issue in rural areas because in some communities and one I'm thinking of, the majority of the community is over 65. And so they saw a significant surge in the need for the vaccine, but even in areas where a high numbers of people qualify, there are cultural issues that we have to work through, trust issues around trusting the science behind the vaccine and trusting the information that people are receiving publicly around public health and public health emergency. And so it really has tested the leadership capacity of rural community members who have been attacked or personally violated or been strained, their relationships have been strained in communities, and yet we still are seeing heroic work from public health workers and primary care providers and hospital leaders and others who are in some cases, county commissioners and city officials that are willing to leverage their credibility to say, "If I've ever asked you to trust me in something, please trust me in this."

And through that and willingness to take care out to people in their homes when they fear leaving their homes, we've seen some remarkable results through that and very, very encouraging ones. And again, we've been pushed into doing things that are uncomfortable, but we've seen people even at their own personal costs make hard calls, engage people in uncomfortable ways as a way of loving them through it.

Lauren Hughes Chris, I'd add a couple things to that and really emphasize and lift up what Ben was saying around trust. That is absolutely essential in helping improve vaccination rates. I think right now we're seeing an overwhelming interest among many individuals and groups that are excited and thrilled to get the vaccine. And then there's a group that is hesitant that is going to require, in some cases, as I have done in my own practice, individual conversations one patient at a time to answer their questions, to normalize their concerns around the vaccine, and to have an open nonjudgmental dialogue about that. And rural primary care is an excellent place for those types of conversations to happen.

And in fact, there was a recent survey that was fielded by the Kaiser Family Foundation of rural Americans that found that 86% of respondents, 86% said they would trust information about the vaccine coming from their primary care provider. That far outstripped the percentage of rural Americans that responded that they would trust the FDA, the Centers for Disease Control and Prevention, their local public health department, and even Dr. Anthony Fauci himself. 86%. That trust is important to leverage and build upon those relationships, many that have been over years and decades in a rural community between those patients and families and their primary care providers.

And the other thing I think it's important as we move forward, we have more and more vaccine options coming on board to think about those vaccines relative to rural and other harder to reach populations. This past February 27th, the FDA approved through Emergency Use Authorization for our third vaccine option that we now have in the US, the Johnson & Johnson vaccine. What's attractive about that vaccine is that it can be shelf stable at normal refrigeration for up to three months and it's one shot only. That could be a significant benefit in, again, our rural and harder to reach communities. And it's important to keep in mind that all three vaccines have demonstrated great success against preventing severe COVID-19 complications.

Chris Casey So clearly while there's no, as they say, no silver bullet guide to address all issues faced by rural health systems, it certainly is important to at least provide a kind of playbook or framework for folks to refer to and share information through. And it seems as though your playbook has accomplished this. I'm curious what the response has been to your playbook and what are the next steps in assessing challenges in rural healthcare and trying to ensure that gains can continue to be made?

Benjamin Anderson Thanks, Chris. I'll take that one. We designed this playbook because of what we know about rural leaders. They are scrappy, hardworking, innovative, resilient people who find ways to make things work with whatever resources they have. I experienced this for 10 years living in a farming community. Farmers often think this way. They make things work on the quick, as they would say, with what they have. And we knew that this playbook or we believed this playbook would resonate. We found that that is in fact the case. We were able to bring a couple of rural leaders from Holyoke and from Vail onto a national presentation a week or two ago where they shared how they've been applying this thing publicly and how they've been rolling it out.

We've heard from folks as the playbook is released to 1,100 hospitals through the American Hospital Association. We've heard from dozens of them saying how this has been helpful, how they've been able to use it to solve their own problems. And there's a therapeutic component to it as well because as people read through it, they see themselves in it and they realize they're not alone and they realize that the pearls from their peers that come through the playbook that I think was really an innovation that Lauren pushed through at the outset, those are really helpful to them because they know this isn't some academic in some university writing about us and making recommendations. These came from among us. And they knew that they had the opportunity to contribute to it.

And so I think one of the most impactful pieces of this playbook in retrospect and as we reflect is that it was designed by them. It was designed by rural healthcare delivery leaders. So it's a great opportunity to say thank you to each of them that gave of their time and their expertise and shared their vulnerabilities in one of the most vulnerable times in their lives to say, "These are what we're learning and here's what we still don't know. Can you help us find answers from some of our peers around solving these problems?" And so this wouldn't have happened without the people that gave us their time, and really also an opportunity to recognize the other seven authors on this playbook. Dr. Darlene Tad-y, for example, she CHA's Vice President of Clinical Affairs, really played a key role in the development of the assessment tool. There are folks at the Farley Center and through the university that really each contributed their own individual expertise into making something like this happen. And we've seen it have a great response.

Lauren Hughes I think the other... I agree, Ben, and the other aspect of the design of this that we're particularly proud of, I would say, and I think resonates well with our readership for the playbook is that this was not a playbook designed to tell the readers of it exactly what to do. That's disrespectful. And we couldn't contemplate all of the challenges they might face and give them a step-by-step guide. This is what you should do and then this problem will be solved. It's not how it works, especially with the diversity, the substantial diversity that exists within rural [areas].

But this playbook was really designed to teach the users of it how to own their own challenges, engage in the problem solving process creatively and together as a team. And we have really valued that approach because it respects the substantial expertise that these rural healthcare leaders already have and bring to the table and really to approach problem solving, not through a deficit lens, but through an assets based perspective. There's a significant difference. And when you bring the ladder to the table, there's no stopping what you can do as a team to solve the challenges that are before you.

Chris Casey And I'm curious given you both have had extensive careers and have accomplished great things throughout your professional lives, where does this project rank in terms of maybe uniqueness and just maybe the satisfaction of doing this in a historic time? This is like a once in a century public health crisis we've all gone through.

Benjamin Anderson That's a reflective question or a question that leads to reflection, Chris. And what comes to mind is this health equity has risen to the center of the national conversation over the last two or three decades, it has largely intentionally or unintentionally excluded rural America. In other words, the inclusion movement has excluded rural America. And I'm not sure that it's been intentional, but we just don't think about it. And this project has been one of the most meaningful things I've been a part of in my career because it is a practical move to include rural America in the health equity discussion. These are tools that can empower rural healthcare delivery leaders to step forward and solve their own problems. And it's also been a very important tool to engage people in Washington around the issues facing rural America.

A couple of days ago, we heard from the Bipartisan Policy Center saying, "We've read your playbook and we need information on these specific areas in rural health equity. Can you meet with us?" And so it's given rural leaders a voice in Washington as well. And both of those have been invigorating, they've been encouraging, and I think they're exciting moving forward.

Lauren Hughes Chris, this is an excellent question. And I would say of all the work I've had the chance to be a part of either from a policy research or a broader policy translation perspective, that this is definitely the top of the list because it was timely, impactful. And Ben and I are now at a phase of this work where we are exploring multitude of ways to get the word out about this and to share with the audiences, not just to talk about it, but to apply it and to engage in the content.

And moving forward, again, with a perspective of this playbook not being something that tells readers exactly what to do, but rather maybe creative ways to approach problem solving and how to build one's capacity or a team's capacity to solve their problems, I think I'm forever hooked on that sort of approach because at the end of the day, it's about seeing and hearing and valuing people and leaders that are doing incredible work. And how can I be a part of actually helping you be stronger, better, more effective, and taking this sort of approach that's not the I'm going to ‘fly in, fly out, fly over’ sort of mantra and tell you what to do, but I'm going to come here and sit at your table.

I'm going to listen and I'm going to learn from you, and then I'm going to do my best to try to bring resources to you so you can own those and use those and apply them in a way that you know is best. And I think that those are really, really important lessons for all of us that care about lasting, impactful, equitable policy change that we need to keep those principles in mind.

Chris Casey Well, I applaud you both and your teams for the creativity and the enterprise, and then lastly, the full execution to accomplish what you did with the playbook. I've read it fairly closely and I was very impressed. And so hopefully as you say, it'll resonate and continue to have an impact going forward. So congrats on your fine work. And thank you for sharing your expertise here this morning on our podcast.

Lauren Hughes Well, thank you very much, Chris. We appreciate it.

Benjamin Anderson Thanks so much, Chris.

[Music - Acknowledgments and Credits]

‘CU Anschutz 360’ is produced by the University of Colorado Anschutz Medical Campus.

Story editing and production by Deb Melani and Chris Casey. Mix and tech production by Kelsea Peters and Matt Hastings. Digital design by Sarah Adams and Jenny Merchant. A thanks to the rest of the office of communications team for support and edits. 

A special thanks to Denver band Splitstep for our theme music, featuring School of Medicine student Matt Golub - class of 22, Daniel Carillo, and Kevin Mackinnon. 

We’d also like to thank our guests this week – Dr. Lauren Hughes and Benjamin Anderson. 

You can read more on their rural health playbook - and the other latest stories and breakthroughs on our campus – at news.cuanschutz.edu

This is CU Anschutz 360.