Asset-Based Thinking: Q&A with Graham Adams

by Allee Mead

Graham Adams, PhD, is the Chief Executive Officer of the South Carolina Office of Rural Health (SCORH). Married and father of three, he has held adjunct faculty positions at several universities, served on the board of trustees for multiple state and national organizations, and served on national advisory committees for the Veterans Health Administration and the U.S. Department of Health and Human Services.

Adams shares how SCORH functions as a nonprofit, how it helped develop statewide plans to respond to the COVID-19 pandemic, and how it's collaborating with the South Carolina Rural Innovation Network to create Digital Economy Ecosystems to improve job training and keep jobs in rural communities.

Tell me about your journey to the South Carolina Office of Rural Health and becoming its CEO.

What makes the South Carolina Office of Rural Health a little bit different than most is that we are not-for-profit. Out of all 50 State Offices of Rural Health, only three of us are not-for-profit: Michigan, Colorado, and South Carolina. The rest sit within a state health department or in a university setting. As a CEO for a not-for-profit, I report to a board and, along with our great team, run an organization of 40-some employees and worry about the business of running the office as well as responding to the actual needs in rural communities.

I got a bachelor's in psychology and I started out working in community mental health with folks who had long-term mental illness. After a few years, I went to the University of South Carolina and got my MPH. After graduating in 1994, I started with the Office of Rural Health in 1995. We didn't have a lot of employees back then ― I think about four full-time employees. Having been here so long has helped me to have a historical perspective of how the office has grown.

My role has given me the opportunity to see how different opportunities arise in rural communities and how we can be proactive in addressing them.

During that time, I went back to school and got my PhD in health administration. Shortly after receiving that, I became the CEO in 2002. My role has given me the opportunity to see how different opportunities arise in rural communities and how we can be proactive in addressing them. I think one of the benefits of being a not-for-profit is that we can see what's coming down the pipe by interacting with rural providers and stakeholders. And as we see a need emerging, we probably have a little bit more flexibility than most SORHs in trying to get in front of that trend, because we can be pretty nimble and act quickly.

How has COVID-19 affected your state, and how has your office responded to the pandemic?

Our office has been central to conversations around COVID planning and response. We were really engaged from day one around trying to devise a hospital bed surge capacity plan. We helped develop the statewide plan for where and when patients would be transferred and what resources rural hospitals had as far as ventilators, staff, and ICU beds. The first few months we spent a lot of time working with rural hospitals, helping to identify PPE for rural practices, and standing up testing sites in rural communities.

We partnered with BlueCross BlueShield of South Carolina, and they identified and procured more than 33,000 masks that we then delivered to rural clinics throughout the state at no charge to them. It was just a great partnership.

We were trying to be strategic about where those resources were and ensure that they were broadly dispersed throughout the state.

We also worked very closely with the SC Department of Health and Environmental Control, the SC Governor's Office, the National Guard, and the South Carolina Hospital Association on identifying testing sites and making sure that rural providers had the resources they needed. We were trying to avoid facilities setting up testing sites across the street on the same day. We were trying to be strategic about where those resources were and ensure that they were broadly dispersed throughout the state. As most SORHs did, we were answering a lot of questions around the CARES Act money ― how those dollars could be used and how they would access the dollars.

We continue to answer a lot of questions around the newly flexible telehealth reimbursement rates for FQHCs and RHCs, trying to make sure that folks understand the resources that are available to them.

We have a community team in our office that spent a lot of time helping with food access issues in rural communities as folks were laid off and unemployment claims rose. We saw the need for food access rise drastically in rural and urban but, in rural, we had partnerships and linkages with a lot of community coalitions, so we could help to stand up some of that work.

We also sat on the advisory committee for the One SC Fund, which was a single source for charitable donations. That fund raised $3 million, which was then dispersed to community-serving organizations throughout the state.

More recently, a lot of our focus has been on the vaccine ― ensuring that it's available to everyone, promoting accurate vaccine information, and advocating for an equity-based allocation method.

Your office received a grant from the USDA's 2020 Rural Business Development Grant program and is collaborating with the South Carolina Rural Innovation Network to create Digital Economy Ecosystems. What can you tell me about this work?

SCORH is helping to think about those things that have an impact on health and health outcomes that are broader than just access to care. So as people become more attuned and appreciative of social determinants of health, that's great, but how do you put those pieces in place? One of the cornerstones is job creation. We have been working with a new not-for-profit in our state called the South Carolina Rural Innovation Network, and their goal is to develop what are called Digital Economy Ecosystems.

Digital Economy Ecosystems feature technical education, job training, leadership development, and community planning to bring quality digital jobs, local entrepreneurship, and remote work opportunities to rural communities. In the past, there's been some training to give folks the skills, but if there are no jobs that they can take, working remotely or in their community, then they just move away and you're not really helping solve one of the core issues in rural communities. Through this grant, we're going to help rural communities create a roadmap for how they are going to develop those opportunities.

It starts with an inventory of what assets they have within the community and how they can take advantage of things like the Opportunity Zones that were championed by Senator Tim Scott from South Carolina.

How is SCORH leveraging Digital Economy Ecosystems to address current broadband limitations?

It's looking at the strengths that are in place and building upon those. It's more of an asset-based way of thinking of things as opposed to deficit-based, which can be difficult for some rural advocates, because so often we're pointing out what doesn't work in order to leverage resources and effect change. Sometimes we have a hard time looking at the assets that are in place and building upon those.

…so often we're pointing out what doesn't work in order to leverage resources and effect change. Sometimes we have a hard time looking at the assets that are in place and building upon those.

As an office, we've been advocating for accessible broadband in rural communities since well before the pandemic began. Our office helped to have the entire state mapped for broadband access, down to the Census tract level in 2019. So those data have been really helpful in understanding who has usable, affordable broadband and who doesn't. During the pandemic, everybody has come to appreciate the importance of reliable internet connectivity in the home for remote work and schooling. Our state took $50 million of its CARES Act money and put it towards broadband access and hotspots for kids so they could do their homework.

This need highlighted by the pandemic really dovetails with the USDA grant. We have to ensure that broadband is available in as many rural communities as possible to empower these folks who have enhanced technology skills. And then it's making sure that there are jobs available at the local level. And they may be healthcare-related skills, like healthcare billing and coding, or they may have nothing to do with healthcare but are still tech-based. If a company wants to contract for back office IT support, they can do that with a small, rural organization in South Carolina just as easily as they can in another state or country. So that project is just getting off the ground now, but we're excited about the opportunities.

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

Back in 1997, we developed a low-interest loan fund, using USDA dollars and investments from philanthropy. We have about $3.5 million that we have the ability to lend, mostly to traditional healthcare facilities: rural health clinics, FQHCs, smaller hospitals, EMS, and all of those folks who are providing care directly. It's for construction, renovation, lines of credit, and working capital. It's very much geared at trying to ensure that the healthcare infrastructure is sustained at the local level. With other partners including some commercial lenders, we collectively lent close to $140 million throughout the years.

The capital needs of rural providers have changed, as a lot of our hospitals are now part of larger systems. A lot of physician practices are also part of hospital systems, so their direct needs for capital have changed. So how do we look at those other things that promote health in rural communities? We started by earmarking a smaller amount of our fund specifically for things that might address social determinants of health. We're just on the front end of that, but we're partnering with another statewide loan fund that is not specific to health, but it does a lot of lending around rural housing and job creation. We're looking at ways to make sure that folks have the resources they need to take something to scale, and part of that does dovetail with the Digital Economy Ecosystems as well, because a lack of capital tends to be a problem for entrepreneurs in more rural communities. We're exploring how we can empower folks who live there and want to create a new business or do something that will spawn job creation.

We're looking at things like rural coworking spaces and potential makerspaces, different ideas that will get folks back downtown and help them to see that there are opportunities for creating a business in their own rural community.

We've all come to appreciate that it will require a variety of ideas and strategies to help rural communities be more viable.

What is your favorite part of your work?

What I really love about my job is that we have the flexibility to address needs as we see them coming and to be proactive. I think that flexibility creates a lot of excitement with the staff that we can actually make a difference.

What I really love about my job is that we have the flexibility to address needs as we see them coming and to be proactive. I think that flexibility creates a lot of excitement with the staff that we can actually make a difference. We have a great team of talented folks working hard to solve some very difficult challenges and I feel like we're making progress.

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