Listening to Rural Stories: Q&A with Alisa Druzba

by Allee Mead

Alisa Druzba is the director of New Hampshire's Office of Rural Health and Primary Care — which encompasses the Primary Care Office, Workforce Development, and the State Office of Rural Health (SORH) — and has held this role since May 2006. She has received the Distinguished Alumni Award from the UMass-Lowell Department of Psychology, the New Hampshire Public Service Award from the Bi-State Primary Care Association, the James D. Bernstein Mentoring Award from the National Organization of State Offices of Rural Health (NOSORH), and the SORH Recognition Award from NOSORH.

Druzba shares how she came to work in rural New Hampshire, how the COVID-19 pandemic has affected her state, and how rural organizations and individuals are rising to meet this and other challenges.

Tell me about your journey to the New Hampshire Rural Health and Primary Care Section and becoming its director.

When I work with NOSORH (National Organization of State Offices of Rural Health) on their orientations for new SORH staff, I always talk about my experience. One of the things I emphasize is that there is no perfect background to working in rural health. Every background brings strengths to it. I have a weird kind of journey, I think, but it's incredibly helpful for me. I use it in my work all the time.

…there is no perfect background to working in rural health. Every background brings strengths to it.

I have a bachelor's degree in political science, specifically in third-world development and international relations, because that is what I thought I was going to do. And I did not do that. I ended up doing some work with a defense contractor when I first graduated from college. And it was a lot around technology but also things I found boring. But the part that was really helpful to me is I became a technical writer, which has helped me in grant writing and a lot of other things.

I have always volunteered with different organizations and really enjoyed that kind of social service work and support. And so when I left northern Virginia to move here to New Hampshire on a whim, I decided to completely change careers. Instead of spending my time volunteering, I would spend my career doing things like that. When I came to New Hampshire, I did residential care in a residential treatment facility with adolescent boys right across the border in northern Massachusetts. I did some outreach work with kids who were at home but on probation for various juvenile offenses, working with their families to help them figure out how to support and work through whatever issues are going on.

I got a degree in a field that is about community, lifting people up, recognizing their strengths and their unique diversity and culture, and not being the expert but recognizing that community members are the experts in their communities. Nothing prepared me more for rural health than that.

I decided at that point to pursue a master's degree in community and social psychology. There aren't that many programs in the country, but I lucked out and there was one very close to me in Lowell, Massachusetts. I got a degree in a field that is about community, lifting people up, recognizing their strengths and their unique diversity and culture, and not being the expert but recognizing that community members are the experts in their communities. Nothing prepared me more for rural health than that.

I worked in a youth development center but I lost my job when the governor of Massachusetts cut the funding that paid for my role there. So it was kind of a kick in the gut, but it turned out to be a great opportunity for me. I really, really wanted to be able to use my graduate work skills and get back into the workforce. I helped out with our town's master plan, facilitating some groups. I met a woman who had retired from the New Hampshire Department of Health and Human Services. She told me how great it was to work there.

There was a job in some kind of coordinator role, now called a rural health manager. Basically, my role at that time would be helping hospitals in New Hampshire convert to Critical Access Hospital (CAH) status, managing that grant. I had the skill set for the work; I just did not have any of the subject matter background. I had never worked in healthcare. I did not understand payment systems, reimbursement, nothing. I applied and they hired me. So that was in October 2004, and I've been there ever since. About a year later, my director left, so I ran the office while we were looking for another director. We gave up looking for another director and I went for it myself. And so I've been the director since May 2006.

What are the main focus and projects of the New Hampshire Rural Health and Primary Care Section?

Instead of being aligned around our grants and the type of funding we get, we align ourselves around specific areas of focus. In our office, our projects fall under access, quality improvement, sustainability, or workforce.

Our projects focus around sustaining the access that exists in rural New Hampshire and then improving it and expanding that access. We program based on the express needs of our community and our providers and stakeholders, and then we align that with whatever our funders' priorities are. Then we create programs that, hopefully, beautifully intersect between those two. And we constantly refine those programs to make sure that our assumptions about how to deliver it are correct, and that our stakeholders are able to access that in a way that's meaningful for them. And we also try to be very innovative. So we will pilot things for a few years and be very, very clear that it's a limited funding time period or amount and then work with grantees to figure out how to sustain it or to have it be supported by another organization.

We have a CAH network that's been going on since before my time here. We deliver all of our quality improvement and our financial and operational sustainability projects to the CAHs through the network. We assess their needs and then we present them with some options on projects. And then we commit to a selected project for three- to five-year periods.

We have a lot of CAHs that are very interested in targeting their community benefits resources in the most effective way possible. And that's a huge culture shift for our folks, who are used to being focused on delivering those things and documenting those things. And now they're very keyed into social determinants of health. The projects that we're working on help CAHs look at small population-level data, using epidemiologists at the department and helping the CAHs figure out how to target those priorities. For example, if they look at the data and they're really focusing in on diabetes outcomes, we're going to help them figure out specific towns that those patients are coming from and then really explore: What are the social determinants that are impacting those patients specifically? And then they will be able to target their community benefits dollars and efforts to alleviating those barriers.

…we're not just presenting them with a problem and saying, 'Good luck with that!' We're going to help them find the solutions.

And then the other thing that we're going to do is use our relationships in public health and the department to connect CAHs with our colleagues who are doing that kind of work. So that way we're not just presenting them with a problem and saying, "Good luck with that!" We're going to help them find the solutions.

What success stories would you like to share about your SORH?

Oh my gosh, we're terrible at this. I mean, we're great at the work — we're terrible at documenting and bragging about ourselves. The five of us are so incredibly passionate and dedicated about our work that we don't really think of it as above and beyond or special. We just think of it as the stuff you do. Every single success we've ever had, it's always been collaborative.

We're lucky that this state has a real history of solving their own problems, and community engagement on an individual level has been systemically reinforced since King Charles II. Getting people on board and convincing people that our problem is their problem and vice versa is not hard at all. Our rural stakeholders are incredibly transparent and they're incredibly honest and forthright about how they feel about our regulations and what's getting in the way and what they're willing to commit to. And so it helps us to understand the field and the environment better so that we can bridge those relationships and hopefully design interventions in a way that accounts for that stakeholder input.

We continue to try to be a voice inside government for these rural communities, not in a way that replaces their voice at all, but that makes more room at the table for their voices.

We continue to try to be a voice inside government for these rural communities, not in a way that replaces their voice at all, but that makes more room at the table for their voices. I would say that our biggest success would be our team's reputation, their ability to listen to the community and the stakeholders, and to try to rise up and meet those needs instead of being wrapped up in what we think is the right thing to do.

How has the pandemic affected New Hampshire and your SORH's work?

Early in the pandemic, our rural areas were doing okay. We had a pretty low-volume case count; our hospitals geared up, they responded, they were ready, and they ended up not having to utilize those resources. Unfortunately now, like many, many other places in rural America, we are seeing a tremendous surge in our rural areas that is a huge strain on the system. It is exacerbating workforce issues in particular.

We have a centralized public health system. Our two cities here in New Hampshire have their own distinct public health units, but the rest of the state is covered by the [state's] Department [of Health and Human Services]. My office has not had to do a ton when it comes to PPE (personal protective equipment) coordination, supply coordination, testing, communication, any of that. That is all being managed by our amazing emergency preparedness and infectious disease folks. My office continues to listen like we always have when we participate in our different groups and meetings with folks, and we try to carry the message up the chain. I'm using someone from our immunization team on a rural health clinic educational session that we're doing in a couple of weeks to specifically talk about what the rural health clinics can do to prepare to vaccinate their patients, how to identify their most at-risk folks, and how to do all of that follow-up and all the logistics that that's going to take.

We spend a lot of time trying to translate federal policy and funding opportunities that come out on a dime and work with our rural healthcare providers on: What is it? Is this applicable to you? What do you need to do? If you take this money, what does it mean? What are the reporting requirements? But for the most part, it's just continuing to do the work that we've always done. That's even more important now particularly around workforce and financial sustainability.

Throughout the whole pandemic, I keep grasping for silver linings. Rural communities understand loss and grief and they also understand that the loss presents them with opportunities, so that's the way I'm trying to look at this pandemic.

Throughout the whole pandemic, I keep grasping for silver linings. Rural communities understand loss and grief and they also understand that the loss presents them with opportunities, so that's the way I'm trying to look at this pandemic. For example, people understand now why broadband is not a luxury item. And I think they understand why broadband in rural areas needs to be supported and why it is critical not only to healthcare but to education and just to generally informing the public.

I also think that the way that we talk about practicing in rural will change. Our perception of incentives for people who chose to work, live, stay, and play in rural will change, based on the way that people's experiences during this pandemic may have changed them.

What is your favorite part of your work?

I am not rural, I was not raised rural, I don't live in rural, but I love rural work. I think that part of the attraction of rural for me is that I never had a hometown. I'm a military brat who moved all the time, and I never really had a hometown or a place that I was tied to. I think the appeal of rural for me is that idea of place and being tied to something and the history of that place and all of that.

I love working with [rural] people who have that perspective and that integrity, and their stories are my favorite stories to listen to. Their stories, their ability to tell a story, to communicate a perspective on something that's really a systemic issue but feels and sounds like a story.

One of the reasons that I love working in rural are really the kinds of people who live in rural and who work in rural. They are unassuming, incredibly dedicated people who really, really appreciate community and who understand the importance of context and history and values. I love working with people who have that perspective and that integrity, and their stories are my favorite stories to listen to. Their stories, their ability to tell a story, to communicate a perspective on something that's really a systemic issue but feels and sounds like a story — I mean, that's amazing to me. And I love to have a meeting with them to talk about a specific focus but also allow some time for them to tell some stories about their community, the things that are happening in their community during this pandemic. I've talked to quite a few folks in our rural areas and we've had time to just talk about what they're seeing and what they're dealing with. And this is personal stuff and professional stuff. And those stories really, really stick with me, and they inspire me to take a look at our role and my team: Is there something that we can do about the things that were identified in the story or in support of them?

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.