“It's the relationships”: Q&A with Peggy Broussard Wheeler

by Allee Mead

Peggy Broussard Wheeler has been the Vice President of Policy at the California Hospital Association (CHA) since October 2005. CHA is a membership association representing nearly 400 hospitals in the state through its policy work and advocacy. Wheeler is the 2021 recipient of the Calico Quality Leadership Award and is also a former member of the National Advisory Committee on Rural Health and Human Services (NACRHHS).

Tell me about your journey to the California Hospital Association, especially your work relating to rural health.

Under California law, hospitals are required to provide specific patient care services in order to be licensed as an acute care hospital. For example, the 12-bed Critical Access Hospital on beautiful Catalina Island near Los Angeles serves its community, but it requires different resources than a large 400-bed hospital in the middle of downtown Los Angeles. Both types of hospitals, however, must meet the same regulatory requirements, regardless of their size. CHA represents the interests of both types of hospitals.

When I joined CHA, I was hired to represent the interests of the small and rural hospitals. And to me, that felt like working on the side of the angels.

When I joined CHA, I was hired to represent the interests of the small and rural hospitals. And to me, that felt like working on the side of the angels. Here are these small hospitals that need to provide the same kinds of quality services in their communities that the large hospitals do, but with a lot fewer resources. These often remote facilities also face unique challenges such as recruiting staff to work in rural communities. It's a particular way of life and not everyone wants to live and work in a rural area. I have such a strong passion for this work. That's why I joined CHA.

My entire career has been in rural healthcare. After I earned my MPH at UC Berkeley, I worked as a consultant with a couple of different companies. I worked primarily in Arizona with the rural health office there. I subsequently moved to the East Coast and did some work with a government contractor supporting physician recruitment efforts for the National Health Service Corps and the Indian Health Service.

When I was responsible for recruiting physicians to work in rural healthcare, whether that was through the Arizona State Office of Rural Health or through the National Health Service Corps or the Indian Health Service, the challenge of attracting healthcare professionals into rural communities always fascinated me. With each successful recruitment, you're so proud of what you're doing because you're actually contributing to the health and welfare of people that choose to live in rural communities. With the hospital association, because we are doing work at the level of advocacy, we're actually protecting the work these professionals do on a daily basis and creating policy that really helps deliver care in all areas of California.

By land mass, California is primarily rural, with a lot of rich farmland. Our rural areas represent a much smaller population than the rest of the state, but certainly we would not be able to have the kind of agriculture and innovation that we have if we didn't support our rural communities. The hospitals that serve rural communities have been there for decades, facing those challenges every day, and our ability to help them through CHA's policy and advocacy work is vital.

You also serve as the Issue Manager addressing concerns like homelessness, language access, and hospital-prison issues. What can you tell us about this work and the importance of addressing these issues in rural communities?

Homelessness is a growing and troubling issue facing the country, not just in California. The number of people experiencing homelessness grew throughout COVID, and it touches our hospitals because homeless people face severe health challenges living unsheltered. Patients experiencing homelessness frequently end up in our emergency departments or in our inpatient beds, and their needs have to be addressed in a unique way. We are acutely aware of our role in providing care and assisting with identifying and linking patients to supportive services, in collaboration with other community-based organizations. We also recognize our role with people experiencing issues with poverty, language access, or transportation — social determinants impacting health status. At CHA, we are aware of these issues and elevate our policy work to address them, in collaboration with community-based partners.

What health inequity issues has the pandemic highlighted or made worse in your region?

COVID really shone a light on an area that we were aware of but maybe not paying attention to, and that is just how much disparity there is across communities in terms of access to healthcare. COVID really pulled a curtain back on those issues, and we saw it in vaccine uptake, for example. And as we are helping our hospitals address all that they need to address in COVID, we found that our rural hospitals were really challenged in doing so.

At the beginning of the pandemic, when we all went home to work and our hospitals prepared for what was going to come their way, one of the first things we and many other states did was to ask our hospitals to delay elective surgery. For an urban or suburban hospital, it has an impact: The revenue stream for many hospitals is their elective surgeries and the care they provide after those surgeries. But for rural hospitals, who teeter on the margins anyway, to turn off the revenue stream and at the same time increase their expenses because they had to get all the PPE, testing supplies, and staff, it really put many of our smaller facilities in jeopardy and they're still trying to recover from that.

We need to pay attention to the inequities and disparities that exist so that we can provide the same access to care for all Californians, whether they live in urban, suburban, or rural communities.

Additionally, our rural hospitals didn't have the same access to the resources that were needed to combat COVID as their suburban and their urban counterparts. Larger hospitals, based on volume purchasing, seemed to have greater access to the sources where they could get PPE. Some rural hospitals struggled to acquire sufficient PPE. Rural residents are generally older, sicker, and poorer than their urban counterparts, and these factors put them at greater risk for severe outcomes from COVID. We need to pay attention to the inequities and disparities that exist so that we can provide the same access to care for all Californians, whether they live in urban, suburban, or rural communities.

Transportation can also be a challenge in rural communities. Many of our Critical Access Hospitals, operating in very remote parts of the state, provide critical care to stabilize patients but then need to transport them to a larger medical center for specialized care. How do you transport these patients quickly when you have only one ambulance available?

What challenges do California's small and rural hospitals face in trying to achieve health equity in their communities?

We've talked through a few of them: transportation, poverty, and resource allocation. Rural hospitals have faced those issues for a long time. And they really look to not only their hospital association but to the state and federal government for support when there is a crisis. And that's the challenge: It's not one size fits all.

It's our responsibility as advocates to make sure that we are appropriately describing the challenges rural hospitals face, whether those are staffing challenges or broadband challenges or transportation challenges or poverty challenges. Rural is not a small version of urban.

When laws or regulations are enacted, we have to remember it may be easier for a larger hospital that has resources available to put those things in place. However, it can be a real challenge for rural facilities. And one of the things I think they really want to raise their voices about is just how much overregulation adds to the cost of providing care. It's our responsibility as advocates to make sure that we are appropriately describing the challenges rural hospitals face, whether those are staffing challenges or broadband challenges or transportation challenges or poverty challenges. Rural is not a small version of urban.

What advantages do these hospitals have in addressing health equity?

I'm so proud to be doing this work because I think that when you're facing these challenges, you learn how to band together. Rural facilities are great collaborators with each other. They don't try to reinvent the wheel each time. They really talk with their colleagues about a particular problem and try to solve it together. We've got some great leaders in our rural hospitals. To be a rural hospital leader, you have to think innovatively. And I think our rural hospital CEOs are strong and innovative. Throughout COVID, these leaders really stayed in touch with each other, brainstorming different approaches to the challenges they were facing. Many of our Critical Access Hospitals support skilled nursing facilities as part of their work. And skilled nursing facilities faced unique challenges such as how to reduce infection among their patients and their employees. These leaders looked to each other for innovative approaches in managing this crisis. That's a real strength that exists between rural facilities, which are more like each other than they're like their suburban or urban counterparts. They really do rely on each other.

There have been a lot of challenges with COVID, but were there also lessons learned from it?

I think about how long we've been talking about the advantages of telehealth, and it wasn't until COVID where they relaxed some of the rules around telehealth that we really understood how this robust tool could benefit patients. But then we learned that many of our remote rural communities didn't have the necessary broadband infrastructure to be able to use telehealth effectively. Telehealth has now become a way of providing care to patients who live some distance from the care they need, reducing the need for travel and the risk of exposure to the virus. Because of middle mile and last mile issues, some rural communities don't have the infrastructure needed to provide those robust services. These issues revealed that we needed to do a lot more work in our broadband infrastructure. California has made a significant investment this last year, $6 billion, to begin that middle mile and last mile work. But we need to make sure that our fervent commitment to that remains, so that we can eliminate or at least reduce that disparity in our rural areas.

What are the biggest challenges you're seeing right now in terms of the healthcare workforce? Do you have thoughts on solutions for those challenges?

Our #1, #2, and #3 issues this year at CHA are the healthcare workforce. Hospitals in all parts of California are facing critical staffing shortages every day. After two years of COVID, healthcare workers are tired, traumatized, and beleaguered, and some are considering other options for work. And because the workforce "bench isn't that deep" in rural communities, hospitals face significant challenges in recruiting and retaining staff.

Many of our facilities are thinking about whether they have enough staff to continue providing certain services in their communities. Do they have enough staff to be able to do surgeries? Do they have enough staff to continue operating outpatient clinics? Do they have enough staff to be able to provide testing in their communities? Staffing shortages have an immediate impact on rural communities because you don't have the employee strength to be able to lose even a few people. That's a real challenge for us.

Another critical component is how well are we doing with the pipeline — in training an adequate supply of healthcare staff to fill positions for those that are retiring? Today, 33% of the state's doctors and nurses are over the age of 55, and across the country an additional 139,000 physicians are needed by 2033. A UC San Francisco study of the state's nursing shortage reports that it will take until 2026 to close the state's current nursing gap.

The pandemic has delayed education and training for thousands of new healthcare workers and slowed the already insufficient pipeline of those who would care for Californians now and into the future. A shortage of student openings in nursing and medical school programs has created enormous barriers to entry into the healthcare workforce, and outdated licensure requirements make it difficult for California to recruit nurses from other states. CHA is committed to identifying solutions to those challenges.

What is your favorite part of your work?

It's the relationships. Being at CHA and supporting rural hospitals for sixteen years, I've had the opportunity to travel throughout the state and visit many rural communities. But it's the relationships that I developed over that time with hospital leaders and the staff that mean the most to me. I admire these professionals so much. They rely on me and I rely on them. We talk regularly so that I stay up-to-date on what's going on. I have a real love and affinity for our small rural communities and what they face every day.

Because of the pandemic, I also have missed in-person meetings — and the chance to connect directly with people. Prior to the pandemic, CHA sponsored an annual Rural Healthcare Symposium. This meeting would bring all of our rural healthcare leaders together in a nice location in California to talk about key issues critical to the work that they do. Unfortunately, we've had to postpone the meeting the past two years. Who knows when we'll be able to meet in person again, but it has made me realize that although people gathered to hear speakers, they really came together to be with each other, to be able to have those conversations with other leaders in their rural communities: to share best practices, to commiserate, and just to be with each other. That's really missing. We have meetings by Zoom, but I think we've all realized how valuable a relationship is in this time of COVID. We've missed each other. We miss the hugs; we miss the physicality. I hope we can get back to that soon. I will really celebrate! I might just throw a meeting with no speakers just to have people be able to come together and be with each other again!

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