Frontline Presence, Building Trust, Emergency Preparedness, and Lessons Learned: Q&A with Dr. Tim Putnam

by Kay Miller Temple, MD

Still residing in rural Indiana, Tim Putnam, DHA, now teaches healthcare policy at the Medical University of South Carolina College of Health Professions after almost two decades of leadership as a rural Critical Access Hospital CEO and work as an EMT. Putnam is an American College of Healthcare Executives Fellow, a past National Rural Health Association president, a member of the White House COVID-19 Health Equity Task Force, and a rural healthcare leadership book author. He discusses perspectives and lessons learned from his past leadership roles as well as discoveries made in his new role teaching healthcare policy.

You grew up rural. Were you always planning a career in healthcare?

Growing up in a rural area, when I was finishing high school in the 1980s, rural was in a recession. My plan was simply to get a degree that came with a stable job. I was fascinated with technology, specifically lasers, computers, electronics, and optics. To understand all of that, an engineering/technology degree was required. I ended up with a niche education that qualified me to work in the research lab of Dr. Leon Goldman, the father of laser medicine. It was an amazing experience. Goldman was an expert who not only worked with the federal government on chemical weaponry safety issues but was the first to find uses for lasers to treat dermatology conditions.

So here I am, in my early twenties, working with famous people doing groundbreaking work. I'm feeling lucky to be in the room and actually having something to contribute. However, it was also a chance to see Goldman's and others in our lab's incredible passion for healthcare. That experience allowed me to understand more about medicine and I jumped feet first into healthcare where my start was with minimally invasive surgery and lasers.

After moving into the healthcare field, you obtained an organizational management degree and an MBA. What was the trigger to your next transition into health administration and eventually to rural hospital positions?

Although I didn't have a clear view of administrative work at the time that I was in management positions, I did understand that leadership was where important decisions were made. Working on the clinical side, I don't think I was unlike many other people in direct patient care: We got frustrated with leadership decisions. I didn't have a good understanding how or why decisions were being made — only that they were having huge impacts on the clinical work. That made me realize that administrative decision-making was worth learning more about and that maybe it could be done better.

Another aspect of my decision was that, compared to other businesses, I thought the business of healthcare was not what it could be. I thought it'd be worth it to further my education in order to understand the business side of healthcare better. That's why I got an MBA [Master's in Business Administration] rather than an MHA [Master's in Healthcare Administration]. Turns out, the business of healthcare does have additional levels of complexity. When I'd be in class or at meetings with business leaders outside of healthcare, that complexity was even more obvious. I'd find myself explaining the complexities of my day in the business of healthcare and how it was much different from theirs. Your customers are patients, and the highest priority is not always a profit margin but the quality of the health outcome. Yet you still have to have a profit to survive. It's just a different game.

Initially, I stepped into leadership roles in surgery and other areas where I had clinical experience. As I transitioned to more leadership responsibilities, it became clear that the next step would either be as a VP in a large hospital or as the CEO in a small facility. I was interviewed by the board at a small hospital in Aledo, Illinois, and absolutely fell in love with what the trustees wanted to do for their community. I felt that this is what healthcare should be and have been dedicated to rural healthcare ever since.

In a somewhat unusual move for any administrator, during your time as a CEO for a large rural healthcare system, you became a clinician serving as an Emergency Medical Technician (EMT). What led to that decision and what was its impact?

As a rural hospital administrator, I already understood the indispensable service EMS provides. I'd always advocated that everybody needs to be an EMT because the lessons learned about approaching medical emergencies can also be applied to critical situations that arise in anyone's professional or personal life. When my daughter was a senior in high school and made the decision to get into healthcare, I encouraged her to sign up for the local EMT night classes. Suddenly I realized I should take the classes, too. For five months, we sat side by side, two, three nights a week, going through the skills training and other coursework.

I'd always advocated that everybody needs to be an EMT because the lessons learned about approaching medical emergencies can also be applied to critical situations that arise in anyone's professional or personal life.

It was a great experience to learn something like this right beside my daughter, but there were tremendous additional benefits, especially when the instructors convinced me that I should do the work as an EMT. They said, “Tim, we know you've taken the training seriously and you've received your certification. But unless you actually run 911, you're not really an EMT.” For about four years, then, I usually ran 911 a shift or two a week, on nights or weekends.

The value from doing that clinical work came from seeing firsthand what people's lives were like at home, what they were having to deal with, the family interactions. I started to take note that the major interventions we did in the ER maybe wouldn't be required at all if only an intervention could have happened there at home even just three or four hours before the emergency call. Through those experiences, I began to really understand social determinants of health and that got me thinking, “How do we fix this?”

From the perspective of a CEO, my EMT work provided a valuable perspective for two projects. First, our community started getting hit with opioid overdoses. An EMT sees that right up close. That helped me with our health system's response for our specific rural community's needs. The second project was our organization's transition to value-based care. Again, seeing and understanding the impact of social determinants up close as an EMT was important to creating a framework for the transition.

On the topic of value-based care (VBC): Your organization was a founding participant in the National Rural Accountable Care Organization (NRACO) and involved in the Medicare Shared Savings Program. You also provided information on rural VBC for the National Academy of Medicine's rural population health workshop. What lessons did you learn from that work?

At the administrative level, our hospital's mission was to improve the health of our community. Joining an ACO was a way to get better at that. However, remember: In order to participate in Medicare's program, you had to have 5,000 covered lives. That limited a lot of rural participation. That provides the first lesson: When limits get in rural's way, find a way to counter them. Join with others in the same situation. Our healthcare system's solution was joining as one of 10 hospitals across the country to form the NRACO, which eventually became Caravan Health.

That provides the first lesson: When limits get in rural's way, find a way to counter them. Join with others in the same situation.

More lessons came from learning-by-doing. Standing out is that, in contrast to urban areas, here in rural we weren't trying to drive volume to a cancer center or to a surgery program. Instead, we were focused on keeping people out of the hospital in alignment with our mission of keeping people healthy. We learned a lot about how to do that, including an understanding of the things that just did not work. In fact, at first, everything we initially thought would work was wrong, especially the focus on those using the most healthcare services. When we started changing the focus to just try to keep people healthier, it was different. We seemed to be so much better at that than tertiary and quaternary centers because we were so much closer to our patients and where they lived.

Yet, still, when we'd call our patients up to talk about scheduling a wellness visit, they'd say, “Why? I'm not sick.” That was a big “aha.” So, we changed the conversation and started talking more about screenings and prevention. That started to make more sense to our patients.

However, I consider one of the biggest benefits from ACO participation was the lessons learned by data sharing.

However, I consider one of the biggest benefits from ACO participation was the lessons learned by data sharing. CMS [Center for Medicare and Medicaid Services] shared all the data with us. We discovered the locations patients were going for their care; we knew how much that care was costing; we knew about 911 calls, ER visits with us or elsewhere. With that data, suddenly we not only better coordinated our care, but we could focus on relationship building between a patient and a home care nurse or a community healthcare worker, or how to utilize paramedicine doing preemptive visits and home safety checks.

From that relationship building and data sharing came several anecdotes of interest. One patient's sugar was not controlled because they'd stopped checking it because it hurt. Turns out, it hurt because they'd never changed the finger-pricking needle. Or another story where the cupboard was full of sugary foods with the diabetic patient telling us they were not going to give it up. Without seeing where patients live and the challenges they face in their daily lives, the transition to value is very difficult.

Without seeing where patients live and the challenges they face in their daily lives, the transition to value is very difficult.

Additionally, the data also helped physicians and other providers to better understand what was happening with their patients. One of my favorite stories on this point was the physician who had very high prescription costs. With a deeper look into that physician's patient panel data, we found that physician also had the lowest number of ER visits and hospitalizations because the patients were actually taking their medications as prescribed. When we can get that type of data, we can start to have conversations we'd never had before.

In the past several years, several types of national events have elevated the need for rural emergency readiness. Share your experiences and lessons gained during your career as a rural hospital CEO.

Crisis situations are where we in rural hospitals and healthcare delivery systems really earn our keep. And it's not just for public health emergencies, but other events like mass casualty events or catastrophic weather events. For a rural healthcare system to be a key partner when these emergency situations occur takes several commitments. First, it requires a commitment to building trust. We have to make the case to our communities that we are not only the healthcare system that is here every day to take care of them when they're sick and injured, but we're also here when all the other bad stuff happens. Making that case is an important part of gaining a level of trust where everyone in town feels, “This is my hospital. This is our community's hospital.”

But that commitment to building trust also means getting out in your community when there's controversy about what's happening in the healthcare system. In those situations, the CEO must be present in the community when that community's railing on the hospital: standing there and just flat taking criticism in a very public forum. Many times, taking that beating actually gains the healthcare leader and the system a lot of respect. It also allows those who support you to come forward and say, “Hey, so-and-so is really fired up about this, but we're glad you're here. How can we help?”

A second commitment is this: Communicate your emergency plan. When there's an emergency, there are so many people who'll just show up saying, “How can I help?” That's an important force to anticipate in addition to the usual formal involvement of law enforcement, community agencies, and other local organizations. Having community casualty disaster drills and working with the local high school to give students a half-day off to participate as surrogate patients help make these plans clear and gets them disseminated in the community. It really helps enforce the concept that we depend on each other, and we are all in this together.

Emergency preparedness also must include the understanding that there will be another pandemic — and it won't be like this one. Additionally, there will definitely be more weather and other catastrophic events that will have major impact on rural communities everywhere. Rural healthcare providers need to have the understanding that a prepared rural hospital is a really key part of the community's response. You've heard it said: Having a fire plan is a good idea, but having a fire department is even better.

Last — and I can't emphasize it enough — is this: Communication during crises needs to be done well.

Last — and I can't emphasize it enough — is this: Communication during crises needs to be done well. As a member of the White House's COVID-19 Health Equity Task Force, I had the opportunity to explore the communication style of many organizations, including federal agencies. I discovered the parallels of healthcare and what the National Oceanic and Atmospheric Administration (NOAA) and its National Weather Service (NWS) do. Just like what we do in public health emergencies, weather teams make forecasts providing warnings that not only save human lives but can also have huge economic impact. I believe their communication framework offers a model that could guide us in providing healthcare communication nationwide — because we know we have to be better prepared for the communication needs that will come with the next public health crisis.

Here's what I think is important about the NWS communication style that could be adaptable:

• Communication of facts: They're not trying to impress anybody with complex scientific language, and we shouldn't either.
• Plain language predictions: Weather experts could speak over everyone's head about what's happening in the stratosphere, the hydrological situation, and other professional jargon, but they don't. They've purposefully created a plain language consistent version of their messaging so that the average person can relate and understand.
• Programmatic two-way communication: For example, their weather spotters program that allows important local citizen feedback. Participants are re-educated yearly.
• Longstanding mainstream media relationships: TV, radio, online sources, and newspapers consistently include weather, usually at the same time and located in the same place in their publication. People can still turn to their personally preferred and trusted local source.

As the rural member of the White House task force — and your other national leadership roles — what “rural realities” did you find most frequently required clarification for non-rural audiences?

Probably the most frequent checkpoint was when those with no true rural experience began to speak as if they had expertise. I recognized I had to break that party up every time it got started in order to prevent the generation of more rural myths, inaccuracies, or suggestions that urban solutions could just be downsized for rural areas. Many times, I found myself asking what perspective the rural folks in the room had offered on a given plan. Usually, the answer was that there'd been no rural representatives invited to be in the room. I'd suggest there should be.

In my opinion, it takes at least living a year in rural America to acquire the needed immersion and lived experience to understand rural. Even then, the understanding is often limited to that specific rural area and not representative of another rural area. Those same limitations apply to me. The fact that I've been to New York City on several occasions does not give me the expertise, only the experience. My comments need to include disclosing that perspective and the same is true for city folk who have only experienced rural areas as a visitor.

Another frequently needed clarification about rural was just the variation of its definition and perspective of what's rural. One person's idea of rural is a town of 700, while another's is 10,000 — or even 50,000. However, we in rural need to own that, even for ourselves within rural America, that definition can be complicated and situation-dependent — let alone that it's recently had changes.

Yet, with all this said, I do look back at my career to date and want to share that my single biggest personal surprise is actually the number of urban experts and policymakers who truly want to offer the right assistance for finding solutions for the challenges we face in rural America. Although it isn't rural-specific, these people have important expertise and we need them.

Now you're in an academic position as a faculty member teaching healthcare policy. How does your rural expertise inform your curriculum?

Currently, I'm teaching healthcare policy — not specifically rural healthcare policy. However, I'm finding that once students discover that I have firsthand experience with the rural results of healthcare policy, they want more information. Because I lecture for several academic institutions, I'm also seeing this interest across the country. This universal interest makes it clear to me that we actually need more people — either more faculty or invited rural experts — to provide these students with the knowledge that this firsthand experience offers. We absolutely need this for the next generation of policymakers and for the next generation of healthcare leaders.

What I also try to convey to students is that in rural healthcare, they'll be able to see the impact of what they're doing up close for people they either know and care about or will come to know and care about.

In my lectures, I do highlight the rural consequences of healthcare policy. What I also try to convey to students is that in rural healthcare, they'll be able to see the impact of what they're doing up close for people they either know and care about or will come to know and care about. I believe having that type of impact is rare in other professions. They'll also be able to discover that when you have the right mix of people who also want to have that type of impact, their joint efforts will go far beyond what they can actually see. As rural healthcare leaders, either as an administrator, a physician, a nurse, or as a technician or a therapist, they can have those experiences. And it's an amazing life.

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