NP Launchpad
In this podcast, a dynamic trio of Fitzgerald Health's NP faculty members show you what works and what doesn’t in clinical settings and beyond. From logistical subjects like licensure, salary negotiation, and documentation to emotional topics like self-doubt and burnout, our hosts guide you through the complexities of practice.
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NP Launchpad
EP 27: Rural vs. Urban Launch
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The region of the country you practice in greatly influences your experience in clinical environments. Here, we give a lowdown on the differences between working in rural areas vs. urban ones, and how you can adjust your skill-set and frame of mind to accommodate the unique challenges of each. Our hosts specifically dive into time-sensitive cases (i.e. stroke), and present resources to help providers spring into action during critical moments.
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Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico -De nino deliver real talk, real experiences, and practical guidance that help you succeed from day one. So if you're ready, let's jump right in.
Christopher GleasonHello, all and welcome to another episode of NP Launchpad. Tonight we're going to be talking about rural versus urban launches. Meaning, where are you where are you going to work? Are you going to work in an urban area? Are you going to work in a more uh rural area? I'm here with my hosts, Vanessa and Jason, as always. Hey! Hi, everyone. So, just a quick plug. If you guys need to contact us for any reason, uh please email us at nplaunchpad @fhea.com. That is nplaunchpad at fhea.com. And a quick disclaimer: this up um our show is education only. Please verify with straight employer and payer rules. All right. So, first up, how does launching and rule practice differ from launching in an urban setting? And what should a new NP expect? Jason, what about you? What do you think about this?
Jason GleasonWow, you know, in Montana where we live, we kind of have a mix, the best of both worlds, right? We have urban settings, which for Montana is like 75,000 people, right? Yeah, somebody from New York, like, hold my beer, that's not urban. That's like a little town to us, right? Yeah, but uh, but we have a good mix in more urban settings and rural, and I'll tell you what, it is such a challenge for those rural NPs out there. They deserve a medal because they truly are in the middle of nowhere. They have big traumas come in, and there's a lot of ranchers around here, and their injuries are not small when they do happen. And so they have a lot of traumas come in and they have to be very experienced. We're gonna talk about a lot of that today. I'm excited for this episode, are you, Chris? I am actually.
Christopher GleasonYeah. When I first started out as a nurse, I actually worked in a role setting. I worked for an FQH. Our our hospital was literally 25 beds. Wow. That did include an ICU and uh uh ER and um childbirth. So I just want you to know we did have the we didn't have all those amenities.
Jason GleasonDid you deliver any babies? I did not deliver any show.
Christopher GleasonAll right. Wow. So when we're first talking about rural versus urban, we need to look at like practice resources. Yeah. What do we have available? What do NPs have available? Yeah. Lee, what do you think? What are some of the urban resources that are available versus what they don't have necessarily in the rural setting?
Vanessa PomaricoSo you know, I've only volunteered in uh federally qualified health centers uh post-Katrina. So, but I do work in uh I've worked in urban settings and uh I'm working in a suburban setting right now, and we have the mix of both. Um I I think that there's uh there's a lot of resources out there, but I think a lot depends on the budget and the budgetary constraints of some of these clinics. And if it's not an FQHC, I think that a lot of the nurse practitioners that work there and the and the other healthcare providers, uh, they really they really struggle because they don't have a lot of resources. I do think that telehealth has completely opened up an area of medicine and made it a lot easier. I know that one of the biggest issues that um the the FQHC that I worked at, which was in Mississippi, um, they used to have, they finally had gotten a uh dermatologist to do some telehealth with their patients. But uh, you know, I think that it's a shortage of a lot of things, not just the specialty resources. You know, if you're working there, as you know, Chris, you need to be an expert at everything. Um but also too, they they didn't have a lot of, you know, samples and that kind of thing that we were so used to getting. And I remember one year I asked one of the uh drug reps if I can get some birth control pills, because they were they really needed some form of contraception down there because they had so many unintended pregnancies, but also the patient population wasn't really being educated about pregnancy prevention. So uh they they they were very, very generous and they sent like a thousand packages of birth control pills, but that was like a drop in the bucket. So I I think that it's really hard that they they suffer from a lot of of um shortages and resources as a result of not having a lot of financial resources. Now, I know a lot of the FQHCs now, um, they obviously they work on grant money and that kind of thing. And so I think they're getting better with it, but I'm just not sure how much. Like Jason, you said it right at the top of the show. You know, these nurse practitioners that work in these rural settings, they are rock stars and they really have to be strong clinicians in order to really take care of the patients. Because, like you said, people come in with a lot of traumatic injuries and they need to be prepared for that. So they really need to be not just primary care, but they need to be, you know, all the specialists and an ED person as well.
Jason GleasonYeah, absolutely, absolutely. Well, imagine this. Imagine a new grad NP. And some of you out there are listening right now, this is your scenario, right? You're a new grad NP, you had an FNP program or adult JIRA, which is the majority of NPs out there, and you need a job and you're from a small town and you want to stay in that small town because you have roots there. So you want to work at the local hospital in the clinic, right? But imagine being a new grad and a major car crash comes in with a flailed chest, you know, huge open wounds, there's only you and another nurse there. I mean, what do you do? So so I actually recommend, I don't know how the two of you feel, but I actually recommend that new grads, they do not, they do not, or they very carefully work in those rural settings. Yeah, you're just setting yourself up for a bad thing. And and and also I think like the constant stress you would be under, like worrying, well, what's gonna come in tonight, right? Yeah without that backup. And often these little towns, I don't know if you've seen this, but they'll have like a physician backup or another nurse practitioner backup. But that doesn't do anything when you have to save somebody's life in five minutes, right? You have to act quickly.
Christopher GleasonSo uh two points on what you said, Vanessa, talking about um telehealth and how much it's it's impacted healthcare. Um when I was doing my DMP project on PrEP, it was interesting because that was one of the topics that they had discussed was the use of tele telehealth to actually increase the um the number of prep prescriptions that were out there because they could reach obviously reach a lar larger patient population.
Speaker 2Sure.
Christopher GleasonAnd looking looking at the FQHCs, unfortunately right now a lot of them are struggling because the grant money was um grant money has been kind of taken away from them at this point. So really they're kind of in a in rock between a rock and a hard place right now. Yeah.
Vanessa PomaricoVery unfortunate.
Christopher GleasonIt is.
Vanessa PomaricoBecause those are you know, really when you think about it, you know, these these rural clinics, those the people that live in that area, they are dependent on that. And without having those clinic accessibility patients suffer. And I remember what you know seeing patients that came in who were diabetic and they had wounds on their feet, but they didn't have the means to get transportation or they didn't have we did we had their own our own pharmacy there. So there again, the grant money would give the patients, you know, enough medication to get them started. But then what? So it's always I always felt like we were constantly catching up. And you know, I I only would volunteer one week a year. So I really was just the person to get them into the system because there was such a backlog. Um but I I I always felt like we were constantly chasing one thing after another after another, and I would follow up on labs or I'd follow up, or even a year later, I'd see the same patient I saw a year ago, and they never came back for follow-up. Wow. You know, again, because they didn't have the means to get there, or it was, you know, they didn't have the the funds to to get their uh their medications and that kind of thing. And it's not like they could mail them because so many of these people, as we know, are transient, right?
Jason GleasonMm-hmm. Yeah, absolutely. It's you know, what are your thoughts on mobile uh vans and like semi-trucks that are mobile clinics on we I think they're a great concept. And in Montana, we actually have several that'll drive out to the middle of nowhere, and the people out there are so appreciative. They line up, they line up, and there's just so many of them in that in those there's just so many of them in those communities and they are so appreciative of the services that are cared for. I think if there's anybody out there that has a passion for serving the underserved, and you know who you are, right? And all of us are passionate about that to some degree. But if you're really passionate about serving the underserved, those people out in the middle of nowhere, I would suggest you write a grant, write a grant for a mobile van or some kind of mobile health care. I think it'd be a great model of care and you can truly make a big difference in people's lives. And what a great opportunity to do that now, since all these states have gotten, you know, millions and millions of dollars from the federal government for grants and in treating uh healthcare needs in rural America. Have either of you worked on a mobile van?
Christopher GleasonNo, I've never done that.
Vanessa PomaricoI have not worked on a mobile van, but it's interesting, rural versus urban. So the the health care, the health system that I work for is a very large health system. And there was a nurse midwife, believe it or not, who got the very first mobile van in our area. And she would go out to the urban areas because again, people, even though they might not be on a bus line and they're not in a rural area, yeah, but they were in an urban area that they would either have to walk to go get their care. And so they brought the van out there and they did needle exchanges. They had a full GYN set up, they had uh mammography there, they had a full lab. Um, and it was really great because again, because of the needle exchange, there was a lot, a lot of that going on at the time. Um, and I just thought it was such a great idea, but like everything else, it all depended on grant money. And if you don't get the grant money, and and now the bus is rotting away in the in some junkyard somewhere.
Jason GleasonAnd what an incredible impact she had, not only on the people that she was serving and treating, but all the babies that were born without birth defects and all the health issues because of the prenatal care that they got. Yeah.
Vanessa PomaricoYeah, she really changed prenatal care in this urban area. It was really wonderful to say. That's true. She was really a visionary, yeah.
Christopher GleasonVery nice. All I can picture is somebody birthing a baby in the back of her mobile van as she's driving eight miles an hour down the highway.
Vanessa PomaricoIt was a huge van. I remember like one of the motorhomes, right?
Jason GleasonYeah. Yeah.
Vanessa PomaricoIt was like a motorhome. It was like an old motorhome that they retrofitted and it really had everything in there that they needed to do the kind of work that they needed to do. Um and again, going to those urban areas where the people were less likely to, you know, to come out and see care.
Jason GleasonYeah, and sky's the limit. Some mobile vans have primary care, they have dental, they have x-ray. Dream big. If that's you out there, write a grant and dream big and go at go after it. Absolutely. Yeah.
Vanessa PomaricoDo it.
Christopher GleasonSo, you know, looking at the urban versus the rural settings, one of the things you have to look at is in the urban settings, they have they have higher patient volume, obviously, because they have more uh higher population. One of the other things we have to look at too is fragmentation of specialties. So, Vanessa, you work in a more urban urban area. Do you see often see those higher volumes, but still lack of access?
Vanessa PomaricoNot so much because um we are the primary care affiliate for, as I said, a large health system. And what the the whole theory behind all this was if somebody went into the hospital or the ED and they needed care, they needed to have a primary care provider, close the loop. And that's kind of how the the premise of how our uh health system started, that anybody that left the hospital who didn't have insurance and didn't have a primary care provider, they were hooked up with social work who would get the patient on some type of insurance, whether it was Husky or Medicaid or Medicare, whatever it was that they needed. And then they were assigned to a primary care provider. So we do see a lot of those people. You know, we have a lot of people that just are non-compliant to begin with. I don't think it matters if it's urban or suburban or rural. I think they're just we're gonna have that segment of the population. But I have to say, by and large, the vast majority of patients are compliant because they do realize the value of having somebody that actually cares about them. And to be honest, I the only time I look to see what insurance they have is to figure out who I need, what specialists I have to send them to. Because we know that a lot of specialists outside of our health system don't take the federally funded um government programs. But other than that, the patients are are very appreciative of the fact that they have insurance and they have somebody that's going to look after them. That's awesome.
Christopher GleasonSo when we're looking at the more rural settings, I think one of the important things that we have to pass on to our listeners is the fact that you really should have pathways in the sense that you they they should know uh who they have for resources, what what what resources are available and you know what what delays with are are um part of those resources. So what do you think, Jason?
Jason GleasonWith regards to the You know, I I think that's vital, right? Vital not only for the provider, but for all the patients and their families that they're serving. You know, Montana, let's let's take stroke, for example, in Montana, right? So years ago, Montana and its stroke system used to be kind of fragmented. Like one hospital in the middle of nowhere didn't know what another hospital had as far as resources. Do they have CT? Do they have you know AltoPlace, the blood clot buster uh drug out there? Um what resources do they have? Do they have life flight that they can fly patients around? And they didn't know. So these patients would have horrific, horrific outcomes from their stroke, because as you know, with stroke, every minute that goes by, two million brain cells die off, right? So time is of the essence. And to solve that problem, or at least help uh providers out in the middle of nowhere, as well as providers in urban settings, I called every single healthcare organization across the state and I logged it all, and there's over 60. So it required a lot of footwork. But I asked every single one, what are your resources for stroke? You know, do you have CT scanners, do you have Alta Place, do you have access to airlifts and medical evacuation services? And we put that on a website. So now, if you get, for example, if you go to Montanastroke.org and if you go to provider tools, you'll find a comprehensive list of all of the different healthcare facilities in Montana and the resources that they have. So in that case, in that case, an NP working out of the middle of nowhere, if they need to know where resources at, they just go to a website quickly and get that information and can get the ball rolling to hopefully help help the patient and save their life. And hopefully it has made an impact. So but I would recommend NPs out there, if you're in a similar situation, whether it's stroke or heart attacks or whatever is out there, know your resources. Do a survey and share the information. Uh we we talked about our last episode about how to develop a website to some degree. Share that information with others because it can be life-saving. So, Vanessa, what's your take on that?
Vanessa PomaricoWell, you know, I agree with Jason. These a lot of these providers, you know, God bless them, that they're working in rural health. But um, I don't think that it's a good place for a new grad to start working unless they have experience perhaps working as a nurse or as a support staff in that area. But I think that they really need to learn hardcore medicine and ED because they're going to be wearing a lot of different hats. Not only are they going to be the primary care provider, they're going to be the specialist. They're going to be managing heart failure, they're going to be managing fatty liver disease and other things that normally we would send off to specialists.
Speaker 2Yeah.
Vanessa PomaricoSo, you know, I really feel that for those people who are out there, I mean, it is it is really wonderful work that they do. Um, but I think that they really need to get the experience working, you know, in an urban area, really get immersed in all of the things you could possibly see so that you are prepared if somebody does come in with a traumatic, you know, tractor accident or, you know, impalement or something. Um, and I think that's the only way that somebody is really going to survive. I know that there's a lot of turnover in rural health. For that reason, people get burnt out really easily. Um, but I will tell you that I met a nurse practitioner. She actually became a fellow with ANP a few years back, and I was so impressed uh with her application, you know, um, when they were reading it off, that I actually looked her up a little bit, and she was one of the only people in her area. She had started one of the um the rural buses that went out to the area, and she had been doing it for like 30 years. Wow. And uh, you know, she was looking to retire, and unfortunately she couldn't find anybody. Right.
Jason GleasonYeah.
Vanessa PomaricoImagine 30 years doing rural health. I mean, that really that's commitment. But everybody knew her. You know, everybody knew her and they all trusted.
Jason GleasonAnd you know, and when you think about this topic, if you're considering a job in a rural area, I don't think this is any opportunity or time when you're gonna fake it till you make it. No, it is not one of those things. And some people might be tempted to do that. Well, I'll catch on, they'll orientate me, I have good support. Or sometimes, you know, like they'll hire you for a position and promise you one thing, and then there's no coverage for the hospital. Let's say they hire you for primary care, and then they don't tell you that you know you have to also cover the hospital or something like that. Christopher, you have an interesting experience about being hired to do one job, and then they put you in an entirely different clinic. Why don't you tell us a little bit about that? They did.
Christopher GleasonAnd actually it's kind of it's kind of funny because it was working for a um a community care center, and I was hired to do initially I was hired to do um primary care and medication assisted therapy. Um and I get out here and they had they had mentioned, you know, hey, we also have a a contract um within the prison system, and you know, would you be interested in in working there? Or it was then they they presented it as if I was just be, you know, kind of subbing in and out here and there, not necessarily working there any any significant amount of time. And then I get out here and the man I get to the I get to the place and they um basically told me, oh, you're gonna be working part-time at the jail and then part-time in the community settings.
Jason GleasonWith no experience in that kind of format, right?
Christopher GleasonI had no c no experience in in correctional medicine. Wow. Luckily I had a good team and and you know, as you can see, I survived it.
Jason GleasonBut you can be surprised. So if you go in for your interview, I would say I want it in a contract, where I'm gonna be working, what my duties are, and what is my backup, and put that in my contract. Because boy, if something falls through and legally you're responsible, you need all of that to back you up. Because I've learned that you know, taking somebody's word for it is one thing, but when it comes to serious things like this, you need it written down.
Vanessa PomaricoRight. And then that's the only thing, if especially if if it's not in your contract, and like you, Chris, you went in in good faith, thinking you were gonna work in one area and the next thing you know, they're putting you somewhere else. That wasn't what was offered when you accepted the position, so that needs to be put in writing. So for our listeners out there, when we talked about contract negotiations in an earlier episode, this is one of the prime examples as to why you need to get it in writing.
Christopher GleasonAbsolutely. Um interestingly enough, though, I working in correctional medicine, I actually did enjoy working in correctional medicine, so it wasn't all bad. It did a great job. It did a great job. So next we're gonna be looking at what an HPSA is, uh what their designations are, what how they how they're utilized in uh rural health clinics, and how they increase access to care. So looking at HPSAs, have you worked in them uh previously, Jason? Do you know anything about them?
Jason GleasonI have, and I actually loved the experience. I really loved it. And I'll tell you what, they paid $60,000 of my loans off. Such a bonus. That was in addition to my salary and every all the other benefits. And beyond the benefits I received, you know, just an opportunity to help the underserved uh populations out there was so great. So yeah, I really enjoyed my time working for an HBSA. How about you?
Christopher GleasonI've never um actually the FQHC I worked for uh was part of a role grant. The um and um can't remember the name of it right now, but the essentially I got sixty thousand dollars of my student loan paid paid off for working within that rule setting, which is a huge, huge benefit.
Jason GleasonAaron Powell Especially these days because resources are drying up left and right. Absolutely.
Vanessa PomaricoSo let me ask you a question. When you worked in the health professional shortage area, how what was your commitment to get the loan repayment? Was it three years?
Jason GleasonThree years, yeah.
Vanessa PomaricoYeah. So for those listeners out there, it you know, this is really an important thing. Um, you know, I uh used to teach for a GEPI program. A GEPI is the graduate entry professional nurse. So people who are non-nurses and become nurse practitioners in a three-year, very rigorous program. Um, and many of them come out with close to $200,000, if not more, um, $200,000 in debt. Yeah. And so the really working in the uh HPSA areas is something that I really encourage people to take advantage of because, as you said, they can forgive a tremendous amount. I believe it was about 70% of the loan that they would forgive as long as they signed on for three years. You come out with over $200,000 in debt. Yeah, you know, 70% of that is a big chunk of money. The problem is that I think a lot of people don't really understand what the HPSA designation means and what it means in terms of being a nurse practitioner. So some of them get in there and say, whoa, this is not what I signed up for. Uh, and then they want to leave, but then they have this mountain of debt. So there's a lot of really good positives that come out of working for an HPSA, not just being able to get your loan repaid for, but I, you know, I don't know about you guys, but didn't you find that the patients were just a Little bit more grateful. Oh by far, right?
Jason GleasonYeah.
Vanessa PomaricoI just found them to be, you know, so grateful. Um, and they thanked me, you know, tremendously, you know, when I was volunteering in the clinic. Um, and I will tell you that there was, you know, I only had one person. Now remember, I'm in the back roads of Mississippi, and here I am coming from New England. Now I don't think I have an accent, but apparently I do. And I only had one patient that said he did not want to see me. Um, he called me a highfalutin Yankee.
Jason GleasonWow. How insulting. Oh my God.
Vanessa PomaricoAnd I said, why on earth would you say that to me? He didn't like how I sounded. And I and I I and I'm thinking, do I have to like, you know, adopt a an accent or a draw or something?
Speaker 2Yeah.
Vanessa PomaricoBut he was the only one that really did like he really did not want to, he was holding on to that that hate the Yankee kind of thing. The rest of the patients were were so very grateful for the the littlest things. And I will tell you that, and again, because they didn't have to pay for anything when they came in, but I had one patient and I knew that this was really coming from their heart. But I had seen them in the course of a week, I saw them on Monday, and then I had to see them back a couple of days later, following them for a, you know, a wound that I was trying to get cleared up before somebody else had to follow up on it. And on Friday, right before I was getting ready to leave, they came into the office and they had two chickens tied up. Two chickens in the office.
Speaker 2Yes.
Vanessa PomaricoChickens, dead chickens, and they offered me their chickens.
Speaker 2Wow.
Vanessa PomaricoBecause they wanted to, you know, send me a, you know, give me something to find. Of course, I was getting on a plane a couple hours later. I don't think I could get on with two dead chickens. Two dead chicken.
Jason GleasonYeah.
unknownRight.
Vanessa PomaricoMy my support staff was only too happy to take the chickens home. But they're they're just a very different um, you know, the way that they approach things and they're just so grateful for anything that we give them. So it's really gratifying work. And I would strongly encourage anybody who has the right background behind them or something that they could think about doing in a few years to really consider doing that.
Jason GleasonAbsolutely. You know, it comes to the analogy that, you know, if you're starving, even a morsel of food you're so grateful for, honestly, right? And all of our patients are grateful. But you're right. I I see, you know, just something special about that population that I just really love and enjoy taking care of.
Speaker 2Yeah.
Christopher GleasonSo interesting um point on the HPSA designation. If you are working for a clinic um that does not currently have an HPSA designation, but you think that the that it would qualify for one, you can actually apply for it. Um you can apply for it at their website, which I found I found that really interesting.
Jason GleasonAaron Powell That happened at the clinic that I worked at, actually. Initially they didn't have it, and then we got it after about a year. So yeah.
Vanessa PomaricoNice.
Christopher GleasonSo we've spoken a little bit about FQHs, and for those that um don't know, it stands for Federally Qualified Health Centers. Um they really work well in uh underserved areas. Like I said earlier in the show, I worked for a 25-bed um FQHC. The patients that we served were so grateful for all of the services that um that we were able to provide them. But there's some interesting things and interesting quirks actually with working at for FQHCs. One of those is there's specific billing roles that you have to take into consideration. Um also when you're working for that FQH, they have a strong focus on access and prevention. So those are the some of the key takeaways from from working for FQHC. And you know, Vanessa, talking on your point, you're so right. They're working within that population, they were so grateful for the care that they were that they were given. And it was just I was really happy for the time that I that I spent there. So when you were working for the HPSA, um, did you have any special building requirements?
Jason GleasonYou know, I did. I did. You know, at one point we thought, I didn't think, but administration thought that we would serve different demographics, you know, to meet their needs. But then rules that we had to follow where you had to serve everybody, anybody that walked in the door, right? And so there are rules like that that you have to follow and uh make sure that you have well documented all the care you're giving because they audit those programs and those facilities on a regular basis.
Christopher GleasonEspecially if they want to keep their grant money, you go across your T's and dot your I's absolutely So uh going back to those uh rural areas and those rural settings, the when you touched a little bit about on this earlier about having a list of your resources and making sure that you know um what you have available to you. One of the other important things to do is to build workarounds, you know, have standing referral relationships, like Jason touched on earlier, you know, getting a hold of those hospitals within the within the state and asking them, what are your resources? What can, you know, what can you provide these rural patients? And then make sure to have clear escalation protocols. If you have, if you have a patient like um you're talking about earlier, you know, patient coming in with flail chests, what is your what is your escalation protocol? Right. In that case, probably not much, unfortunately, in those in those role settings. But you know, make sure that you have that laid out for you. And even when you're doing that contract negotiation, that should be something that you discuss with those, um, with whoever you're doing the contract with. They should have those things in place for you.
Jason GleasonWell, and isn't technology amazing in those situations too? Because you know, back to stroke and our stroke program in Montana, you're in the middle of nowhere. Who do you call? You don't have a neurologist down the street, right? Like you would in an urban center. So I'll tell you what, telestroke for our rural states across the entire country, even urban locations are using telestroke because patient comes in the door. Let's say you work out in the middle of nowhere in this small little critical access hospital. Patient comes through the door, usually delivered by their family because they didn't call the ambulance, right? So on the back of a truck, something something like that scenario, they come in your door, they're having a stroke, time is of the essence, you got to find out what is going on right away and treat them. Well, telestroke, and it's the most amazing thing for telestroke. A TV, a computer, it's all in one station. They pull that up to the bedside, they dial in. A neurologist is at the bedside within five minutes usually, and the neurologist can do the complete exam from telestroke, look at the imagings, uh, the images that are being uploaded, and then make decisions and help that person out in the middle of nowhere make those critical decisions whether to give TPA or not, um, or TNK or not, and uh and hopefully save the patient's life. So telestroke can be so life-changing and life-saving. Have you seen any other telehealth models out there?
Christopher GleasonUm I think the telehealth uh I touched on it a little bit earlier for my DNP project. I worked in uh worked on PrEP access. And the I was reading through the articles, and it was really interesting how how much telehealth increased access to prep because a lot of the times with prep, some of the things that you know are are uh blocked to using it are um you know readily available providers to prescribe it, uh patients that are unable to afford it, patients that are unable to meet with the um with their providers for the required uh follow-ups, and things like that. So telehealth really kind of had that, um, was able to change that field for a lot of people.
Jason GleasonAnd you know, out in um rural America, if you're out there working at these hospitals and small clinics, check in with your Department of Health and Human Services in your state, because in Montana, for example, for Telestroke, we have an entire program that is grant and federally funded and state funded that'll help those smaller facilities get the software and the equipment that they need, and along with the subscriptions to the telestroke services, that's the big cost where you're paying a neurologist, you know, to give you those consults rapidly, because the neurologist is usually at a big center. So check in with your Department of Health and Human Services and see if there's any programs out there so you can get the resources that you need, because often there are, but often they're not asked about. So don't do that. Make sure you ask.
Vanessa PomaricoI also think that a lot of these health centers, these rural health centers, they they've been running for so long that when you go in there, they already have one of those resource books available. Yeah. And that would be something you would just want to make sure that you know had access to. Um and I just I know that with telehealth, they even if patients don't have smartphones, because let's face it, they're living in rural America, they may not have access to computers or uh, you know, a smartphone. And so they can actually come into the clinic, and I've actually seen um the them utilize the computer, and they're able to do a telehealth visit, let's say, with a cardiologist for heart failure. So instead of going to a heart failure clinic that might be two or three hours away, they're now able to do it via telehealth. So, really, telehealth has really changed the landscape of our uh specialty referrals in terms of rural health.
Jason GleasonIt is. It truly is. And they have, you know, telestroke, they have tele-ed, they have teleICU, they have a bunch of different formats out there. So check your resources and check in with your Department of Health and Human Services.
Christopher GleasonSo when we're and uh interestingly enough, we're talking about resource maps. So when you're building that resource map, uh something important to look at too is include look at the logistics. Look at transportation issues, after you know, after hours pharmacy, emergency contacts. Because a lot of times in these rural settings, you're not gonna have, you know, the um you're not gonna have access to those pharmacies because they f the pharmacies could close, who knows, you know, at six, and later on in the night you're not gonna have any access to any uh pharmacy at all.
Jason GleasonWell, and as Vedesta mentioned, often in these places the work's already been done for you, right? Because they've dealt with these issues for years, the previous providers. But what do you do? Let's say you're in the middle of nowhere, there's a snowstorm, flight cannot arrive to pick up a patient that is a trauma or needs critical care, right, in a bigger facility. You have to have a backup plan, right? And who's going to pick them up and where do you take them, those kind of things, or what do you do to keep them alive until until somebody can come and pick them up? So I completely agree. You have to have this mapped out ahead of time. But Vanessa, you're right. Often it's done for you, but often things need to be improved. And your ideas that you have out there, our listeners, you have some great ideas, I'm sure, on how you can improve rural healthcare. Share those because you're our future.
Christopher GleasonAnd make sure to update those resources on a frequent basis because you, as we all know, things can change and they can change rapidly. So it's important to have a an uh um up-to-date list.
Jason GleasonTrevor Burrus, Jr.: And if you have a facility policy or guide or whatever you come up with, make sure, make sure that you follow it to the T, right? Because some facilities have volumes, they have binders and shelves full of tools, guidelines, algorithms, and they don't follow them because they're difficult to do or they haven't been done forever. But if there is a negative outcome for a patient that goes to a malpractice suit, those lawyers are gonna be looking at all those guidelines. And if you didn't follow them, if they're written up for you and you didn't follow them, that's a big deal.
Christopher GleasonAbsolutely. Exactly. Uh Vanessa, I'm I'm kind of uh interested in your take on this. So let's say you are working in a rural setting, okay? And how would you build relationships within the community while maintaining that healthy professional boundary? What's your take on that?
Vanessa PomaricoSo, you know, I think that that it's doesn't matter if you're in a rural area or not. I think we have to have those healthy relationships with our patients. But I think it takes on a different, um, a different relationship because small towns are small towns and everybody knows one another. And I think that when you work in an area, rural area, um, the boundaries are a little bit more blurred than what let's say the three of us would see in our day-to-day, because we're not living in small town America. Um, but I think those relationships really have a very different uh they they're they just are they're different because they the healthcare providers are such an integral part of the community. And they, you know, they go to church together, they do, you know, um parties together, they might have picnics together. So I and I think that people genuinely in the rural communities, they respect the healthcare providers in a way that they generally won't cross a boundary. I could be wrong about that, but um I I just know from what I saw, uh, very generous and gracious people. Um, you know, it's just uh one of the stories I always tell is my husband is a Red Cross volunteer, and when he got um deployed to Katrina, and that was a really horrific, he was gone for over two weeks. Uh, you know, I worried about there's no food, there's no electricity, you know, what's gonna happen? Like, is he gonna be able to shower? He's gonna eat well. And uh the the community church where they because they were all sleeping and that they had uh all the cots put into the um the basement of the church, the church women came by and they would cook hot meals for them every night.
Christopher GleasonThat's awesome.
Vanessa PomaricoSo I think that that's it really is, but I think that's what happens with communities. They come together, you know, not just in a crisis, but I I think that the communities just all work together. And and as far as being the healthcare provider, I again I think there's some healthy boundaries there that are just inherent because that's just how the community views the healthcare providers.
Christopher GleasonAbsolutely. And and it's so important that when you're building that relationship, you know, show up, make sure that you you follow through with with your plan of care. Right. And make sure that you're communicating clearly with with your patients. One of the other things to look at too is make sure that you respect local culture without without losing those boundaries. You know, Vanessa, you kind of touched on this a little bit when you were they were they tried to pay you in shit, yeah. Yeah. You you were very respectful with them, but you know, still didn't cross that uh cross that boundary.
Vanessa PomaricoBut I I also knew that that was a huge thing for the patient.
Jason GleasonYeah.
Vanessa PomaricoBecause those two chickens probably would feed their family for an entire week or longer. Right. And I I I didn't want to say no because I didn't want to offend them. Um but you know, I I I I mean I did. I felt terrible that the the I wanted to say, oh, you know, thank you, it's not necessary, but I didn't. I knew enough. And and that's one of the things, and you're talking about the culture, Chris. You really have to do your homework on the culture so that you don't offend anybody. You know, one of the things it, you know, being a New Englander, we don't use Miss or Mr. before we say somebody's name. But in certain parts of the country, you always say Mr. Jason, Mr. Christopher, Miss Vanessa. Um, and that's just a sign of respect. So you have to do your research not just on the patient population, but the culture that you're going to be serving as well. Because if you want to make an impact, you want to make a positive impact, and you don't want to be known as the person that's offending everybody. The outsider, right?
Christopher GleasonAbsolutely.
Jason GleasonI love that. You know, when I worked for IHS, it was such an honor to get a blanket from one of the tribes. Yeah, that's one way that they honor people or beads. Uh this one woman actually beaded a stethoscope for me, you know, the case on the outside. It must have taken her months because little tiny beads, right? And such a wonderful art design, but yeah, understanding their culture and it can be fun because you're learning new things about different people. Yeah, and and they'll learn about you as well. So what a great opportunity.
Christopher GleasonAnd and definitely remember the relationship you build with the patients, especially in those rural settings or in settings in general, not just rural settings, is often the strongest medicine you have.
Jason GleasonYeah.
Christopher GleasonIn the sense that you know, if you have that relationship with them, they're gonna trust you, they're gonna follow your plan of care, and they're gonna, you know, continue to come back to you. Yeah. Yeah. So next up, let's look at some resources to share. You guys don't have to write this stuff down. It's actually in your show notes. So first up we have the Health Resources and Services Administration, the HRSA. One of the other resources is Real Health Information uh Clinic. Again, you can find that link in your show notes. Important link though is this the one for Centers for Disease Control and Prevention. Uh looking up the social determinants of how that can be. I love that information. That's a good one. All right. So next up is our favorite part of the show. We're looking at fact or fiction.
Jason GleasonCue the music and the confetti, please. Here we go. Right? Let's do this. I'm still waiting too, crazy. I know. The no prizes. Dang it, we gotta get some.
Christopher GleasonYes. All right, Vanessa. Rural practice often requires broader scope and stronger community partnerships. Fact or fiction?
Vanessa PomaricoThat's definitely a fact. If you don't have that broad scope and that confidence to carry that through, you're gonna drown.
Christopher GleasonAbsolutely. Yeah. All right, next question. Jason is up. You're up. Let's do this. Resource scarcity can be offset by strong referral networks and local knowledge. I would say yes, yes.
Jason GleasonAnd these people out of the middle of nowhere, they truly know how to do this well, right? Work with absolutely nothing. So know your resources.
Christopher GleasonAbsolutely. So, Vanessa, urban practice always offers more autonomy than rural practice. Fact of fiction.
Vanessa PomaricoThat's a hard no fiction. Uh because, you know, in urban practice, you can just say to somebody across the hall, hey, can you come over here and look at this with me? Yeah. You're in a rural practice, you're at babe.
Christopher GleasonThat's it.
Jason GleasonThat's it.
Vanessa PomaricoYeah.
Christopher GleasonAll right. Jason, building a community resource list can improve outcomes quickly. Fact of fiction.
Jason GleasonAbsolutely. Like I mentioned, MontanaStroke.org. We got a map there for all the resources across Montana for stroke. You can do that for anything, though. Anything. So yes.
Christopher GleasonAll right. We want you all to know that we appreciate you so much. So one of the ways we want to show our appreciation is to give you a discount code to FHEA.com. The code is launchpad20 for 20% off all CE and memberships. It's just a way for us to say thank you for supporting the show. Again, that code is launchpad 20 for 25% off all CE and memberships. All right. Next up, let's look at our mailbag. If you have any questions for us, you can email it to nplaunchpad at Fhea.com. That is nplaunchpad at FHEA.com. And we actually may answer some of your questions on the show. All right. What's the biggest surprise about rural versus urban practice for you so far?
Jason GleasonWhat's the biggest surprise? I would say, again, it was I don't work in a rural area right now. I work for the VA, but um I would say just the shock of not understanding how little resources you have in those areas, right? And to scrounge for the resources and to get something well in place so you can take good care of patients.
Christopher GleasonAbsolutely. Absolutely. And Vanessa, we touched about um on this a little bit earlier in the show, but how do you how would you build a local resource list when services are limited or referrals are far away? What would you look for?
Vanessa PomaricoSo I would again look to see what they've used so far. And then again, these this is small town America. Get involved in your community and start building more resources that way. Don't be afraid to ask. If you don't ask, you won't get it. But I also think that the people that work in rural care, they are incredibly resourceful. So they find ways of, you know, making things happen, stretching a dollar, figuring out where to find the funds for something. But don't be afraid to ask and just build upon what's already been there.
Jason GleasonI love that point. You know, and to add on to that, you know, in Montana, there are places in the middle of nowhere, but they're often part of a bigger healthcare system. You know, all these hospitals have bought up or partnered with a lot of smaller facilities. And they do have plans in place. And those larger facilities really support those smaller towns and smaller areas, and they're a lifeline for that.
Christopher GleasonAbsolutely. So next up, we're going to be looking at our landing checklist. So this is sort of homework for you. We want you to identify the nearest transfer site. It'll just it'll help you build that resource list and help you when you get out there to practice in those urban areas. And you know, the Vanessa, you actually touched on this. Meet local public health leaders, go out into the community, find out what you have available to you, find out where you can transfer.
unknownRight.
Jason GleasonAnd just like on Shits Creek, the mayor might be the janitor and the you know, it might be just one person, right? Exactly. Yeah.
Vanessa PomaricoThat's exactly what I was thinking of when we were planning this episode. Was like, uh, did they even have a clinic in Schitz Creek?
Jason GleasonI didn't see one. Did you see one?
Vanessa PomaricoI didn't see one. I didn't see it.
Jason GleasonDid you see one? They had a vet. Oh, they had a vet. So everybody had to go to the vet to get their healthcare, right? Yeah.
Christopher GleasonAnother thing to look to look to do is uh building that cheat sheet, uh, that local resource cheat sheet. Look for your pharmacies that you have available, labs, transportation, shelters, urgent dental actually uh is important as well. So for your homework this week, be sure to build a one-page community resource list for your clinic's uh most common needs. We want to say thanks for everyone for joining in. And if you would, we would love it if you dropped five stars. Um please drop five stars if you thought it was worthy. If not, please email us. Let us know, let us know why. Maybe there's something that we can uh work on. Uh hit that follow button. It helps the algorithm. Tap subscribe. That also helps the algorithm so we can reach more people, get out into the community and share the knowledge. Most importantly, please share this podcast with all of your friends and colleagues. Even if even if they're not enough practitioners that are thinking about going into nursing, or they're nurses that are you know dabbling in um or thinking about going to become NPs, share this resource. It's a great resource for them. All right. So that's a wrap for this week. Uh, Vanessa and Jason, any parting thoughts?
Jason GleasonNo, no, get out there and make a difference.
Vanessa PomaricoThat's right. Thank you. Good luck, everyone. Yeah, thank you.
Jason GleasonThank you, everyone. See you later. See you next time.
Christopher GleasonBye now. You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.
