NSHC board hears concerns about 24-hour call line
By Megan Gannon
The board of directors of the Norton Sound Health Corporation convened last week in Nome for its first annual meeting in person since the COVID-19 pandemic began. The public comment period was delayed due to a technical difficulty, and when the line opened on Tuesday, Feb. 14, callers told the board of frustrations with the villages’ reliance on a call line to receive 24-hour care.
“People shouldn’t have to call out to outside the village seeking help,” said a caller. “It’s not right. I think they should put a dispatcher at the clinic, and I think they should hire more people that work at night…They need one or two people that can take care of true emergencies.”
Another caller said that residents of the Lower 48 “have the luxury to call 911 when somebody’s life is in jeopardy—we want that too in the villages. We want to be able to get a response.” She urged the board and the administration to get “right on top of the situation” and to use their experience in dealing with the bureaucratic world to look for the funding and resources to get the village clinics staffed at night.
NSHC’s call service was introduced in 2017 and was formerly operated by triage nurses. It has been renamed the “provider care line” because it is now meant to be staffed by “advanced practice providers,” such as physician assistants or nurse practitioners.
NSHC Medical Director Dr. Mark Peterson responded to concerns about the call line during the meeting. He acknowledged that the provider care line is not as good as having someone on the ground. “However, it works well a lot of the time,” Peterson said. He said that in some cases the medical situation determines the bad outcome, even if it seems like the provider care line is at fault.
Careful to avoid sharing information that might violate privacy rules, Peterson addressed one case that a caller mentioned where a patient died after being advised by the triage line to wait until the village clinic opened to be assessed for care. NSHC received a complaint and investigated the case, he said.
“We know this patient later died, but when they did an initial evaluation, the evaluation showed the patient was at that time doing OK,” Peterson said. “They were advised to be seen later in the morning. They did get seen later in the morning…When they did get seen they were worse and then they rapidly declined after that because of their condition. I can’t get into the specifics of the condition, but our review of that case showed that the death was because of the type of illness this person had and rapid decline, and it was not because of the delay in recognizing that.”
Peterson said that ideally every village would have a physician, two advanced practice providers, three health aides and a 911 system. “We would like to get there where we have all of that in every village, but we have to take steps to get there,” he said.
Unreliable communication systems—with frequently dropped calls or problems with carriers—make it dangerous for the village to have to rely on calling to Nome for emergencies, another caller commented.
NSHC CEO and President Angie Gorn responded, noting that communications issues were also a problem when health aides were on call in the villages.
“Back when we had health aides on call and you couldn’t get to them, you had to physically go to their home and track them down,” Gorn said. “We’re looking for a different process. We know we need some type of backup system. We just don’t know exactly what that looks like for each village. But we are working on something, so your concerns have been noted. I don’t have a solution to share with you today, but it is something that we’re working toward, and it’s a very valid concern.”
Board Chairman Preston Rookok thanked the callers raising their concerns.
“These are the things we need to hear,” Rookok said. “We appreciate the comments and call our public makes. It makes us aware of what we need to fix, and time is critical. We know that.”
Later in the week, the board heard a presentation from NSHC’s Megan Mackiernan on data analyzed from more than 22,000 calls the provider care line has received since 2017. Mackiernan said that most calls seemed to be coming in at night after the clinics closed, with the biggest chunk of calls from 8 p.m. to midnight.
About 41 percent of the calls were labeled emergent, meaning that the patient needed a visit or care immediately, Mackiernan said. In 7 percent of the cases, a provider or health aide went to the patient’s home. About 15 percent of callers were advised to follow up during regular clinic hours, while 26 percent of callers received advice or instructions on how to take care of their issue at home. In less than one percent of cases, law enforcement was called. Another 8 percent of the time, the incident was not considered an emergency, but patients got to speak to a provider anyway. Callers were connected with Behavioral Health Services in less than 1 percent of cases.
Mackiernan broke down the most common reasons for calls: gastrointestinal complaints, followed by skin issues from rashes to minor injuries, then orthopedic issues ranging from broken bones to sprains. About one in 22 calls dealt with a psychiatric issue.
Mackiernan also compared the calls from villages that were served with water and sewer and those that were unserved. “In general, in unserved communities, we actually see higher rates of injury, those orthopedic injuries, more skin problems, more mental illness calls, more stomach complaints,” she said.
When the meeting closed on Thursday afternoon, Golovin’s representative Charlie Brown told the rest of the board that they should use that data to help build momentum for better sanitation and housing for the region.
“That data there shows us we have a lot of need in those areas of sanitation and housing,” Brown said. “Instead of thinking of better ways to answer a phone, I think we should be looking forward and preventing all those calls from happening.”
Other business
During the three-day meeting, the group re-elected Rookok for another term as chairman. Tony Haugen of Unalakleet was elected first vice chair, Heather Payenna of King Island was named second vice chair and Berda Wilson of Council was elected Secretary. Wilson was also voted Board Member of the Year. “I’m just very humbled and honored,” she said. “I just wanted to voice how far we’ve come and how happy I am that we have a healthcare provider owned by our people. It’s been a long road but look how successful we are.”
In her report to the board, Gorn noted that NSHC would soon be celebrating 10 years since moving into its current facility in Nome. She said that in that decade, NSHC’s system, including its village clinics, has nearly doubled the number of annual health care visits, from 80,000 to over 150,000 today. The amount of cash collections in that same period has also increased from $26.5 million to $85.1 million.
“We have to keep our volumes up or that number will go down because, again, it’s contributing to a huge part of our operating budget and it’s based on the level of care we’re providing,” Gorn said. In September the board passed an operating budget of $232 million, only about a third comes from Indian Health Services.
“We’re just like any other healthcare business where we have to provide high quality care and bill for that care to be able to do everything that we’re doing here,” she said.
The old hospital in Nome had an average of four patients at a time, Gorn said, but today the average is 13, even though the newer facility has the same number of beds, 18.
“Our goal has been to utilize the space we have and make sure that we’re providing enough care in region so patients don’t have to be transferred out, and so that their needs are met before they go home to the village,” Gorn said. She said the full-time psychiatry services available at NSHC help make this possible.
“That’s something other tribal health organizations do not have,” Gorn said. “It’s something we implemented a while ago that allows us to provide treatment for our patients here locally instead of having to transfer for those services.”
NSHC has also made more walk-in appointments available in Nome, which has helped reduce ER visits by 36 percent and grow primary care visits by 68 percent over the last 10 years, Gorn said.
“We’re really proud of this,” she said. “This is exactly what we want to see. But it still isn’t perfect yet.” To address complaints about wait times for walk-ins and same-day appointments, she said Dr. Peterson is working to free up more time in the providers’ schedules by shortening typical appointment slots to 30 minutes, instead of 45 minutes to an hour.
NSHC filled 55 hard-to-fill positions since June, Gorn said, but she acknowledged that during the past three years, recruitment has been difficult. Some staffing gaps were clear in the hospital’s data. For example, NSHC performed less mammograms to screen for breast cancer in fiscal year 2022.
“The barrier there was just the inability to even find contract staff,” Gorn said. “It doesn’t mean that women who needed care weren’t able to receive it, they just had to travel out for that if it was a diagnostic mammogram. So that’s one of our goals is to get caught up and get those numbers back up to what we want them to be.” She said NSHC now has a temporary mammographer who may extend the contract if the hospital can’t fill that position.
In his report, head of human resources Charlie Cross said 69 new employees have been onboarded in the last six months, with 58 of those in permanent positions. But over this six-month period, NSHC also averaged 186 vacancies and recorded 61 voluntary resignations. Of all NSHC employees, 58 percent are tribal members. In Nome that number is 48 percent, and in the villages that number is nearly 90 percent.
Gorn said that one of NSHC’s top priorities is expanding its nursing home, the Quyanna Care Center. Construction for that expansion will begin this fall and the facility will add 12 beds. It currently has 18. There is already a waitlist of patients, some of whom may already be in-patients at NSHC. When the state funded Nome’s replacement nursing home facility 10 years ago, the cost was $18 million, Gorn said, while building an expanded 12 bed unit today costs $27 million. NSHC is also considering creating a multiuse building that would include a childcare facility, an assisted living facility and extra patient housing in the next few years.
The region’s housing shortage was a common thread throughout the meeting.
“As we’re all expanding care, we’re all feeling the need for more workforce, which means more housing in our communities, whether it’s Nome or the villages,” Gorn said. She announced that NSHC just signed an agreement to work with John Moller, who was Gov. Mike Dunleavy’s longtime rural affairs advisor until he resigned in 2021. Moller, who was introduced to the board over Zoom, will be looking for funding for NSHC’s housing-related needs through legislative and federal sources.