Diversion Programs in Rural Settings with Carin Yale, CPhT Controlled Substance Coordinator at Avera Health, Thomas Johnson Pharm D, MBA, BCCCP, BCPS, FACHE VP Hospital Pharmacy and Laboratory Services at Avera Health, and Jeff Kauffman RPh Director of Pharmacy and Professional Services at Hillsdale Hospital.
Are there unique challenges in rural hospitals when it comes to diversion and employees with SUDs? Do these facilities tackle these issues the same way a larger institution would? Join me as I ask these questions of three people who have extensive experience in rural communities. Hear their thoughts and what they are doing as organizations to address diversion in critical access facilities.
Transcript:
Terri
Welcome back, everybody, to diversion insights. Today, my guests represent health care in rural communities. And that is the topic of the discussion. Tom Johnson, The VP of Pharmacy And Lab and Carin Yale, the court the controlled substance coordinator, both from AmeriHealth are returning guests. And we also have Jeff Kauffman, the director of pharmacy at Hillsdale Hospital in Michigan. So welcome all 3 of you. Until we work in a rural setting, I don’t think that we can really appreciate the unique challenges that they experience, which is why I asked our guests here today to share with us. There may be some of you listening who struggle with some of the same things, and you’ll benefit hearing some of their ideas or just simply knowing that you’re not alone. In the struggle. Jeff, let’s start with you. Give us some of your background and demographics of your hospital.
Jeff
Well, director of a small rural hospital, about 97 beds. Total But about a third of that is a skilled nursing unit. The rest is general population, and we are a small town, Hillsdale, Michigan. We have Hillsdale College, which is pretty much the biggest employer. And then it’s some industry and mostly farming community. So we serve Hillsdale County, some of Branch County, and then the surrounding community going around as well as a fairly large ommish population. Okay.
Terri
Now your hospital contracts with the hospital solutions group, which helps you, I’m sure, with some of the resources. Yes. For go ahead.
Jeff
Well, CPS, I’m contracted through CPS, and pretty much they give me a host of tools. I report to our CFO here, what CPS gives me the tools that I need to stay on track, stay compliant, and look for any red flags that may come up as well. A whole host of other ideas and to sounding boards from my peers?
Terri
Sure. So I would assume there are some of those tools are for diversion monitoring, resources, but when it comes to culture and then responding to diversion, is it safe to say that falls largely in the hospital’s lab and not the contracting company?
Jeff
That is more on the hospital. Yes. Okay. If we find issues and have anything pop up, We take approach 1st and foremost, look into the situation, sit down with the individuals, If there is a substance abuse problem trying to get them help, save their career, get them enrolled, old, at least in Michigan, in the health professional recovery program. So, hopefully, we can get them better, save a career, save a health professional and take care of it that in that route.
Terri
Right. Okay. Great. And I think that’s one thing I wanna talk about today. I’m wondering if there are differences when it comes to rural versus larger, or if, really, the difference is that because it’s a smaller community, we handle them with more compassion, which really shouldn’t be different than, you know, the larger hospitals. Right? So I wanna talk about that too. But, Jeff, you had mentioned that you are very involved, the liaison with the board of pharmacy, and state licensing boards. Has that given you any insight into how rural hospitals in your state, excuse me, maybe differ from larger institutions in terms of the approach that they take or culture or diversion investigations.
Jeff
I have 2 close friends that work in row hospitals and then a couple that work for the larger hospitals and it just seems the smaller hospitals wear more hats, but we’re more involved. And it’s easier to know Not everybody, but pretty much you see those faces go by, and there’s a little more personal touch when you’re in a bigger hospital setting, and I just go back to I worked at 1 of the bigger Detroit hospital when I was on my externship, and you pretty much were at that base just walking by, and you might see the same base a couple times. But it was just a bigger atmosphere and to try to keep track for the HR group and everybody else, I think it would be a bigger challenge.
Terri
True. You’re more of a number than a face. Okay. Tom and Karen, your hospital group represents some larger facilities and then also some rural facilities. So, obviously, you can see a difference if there is a difference. So give us an overview of that, and what do you see in terms of differences or are there differences in approaches and cultures related to merge in?
Tom
Well, I’ll start. The very health covers 72,000 square miles. Of rural countryside. I think we’re at 30 eight facilities, most of which are considered critical access. So we’ve got.
Terri
Oh, oh, okay.
Tom
Think it’s either 5 or 6 that are not critical access, which means 25 beds are smaller. More than however many miles away from nearest other facility. So we have a lot of facilities where there are individual people doing a lot of these roles where a lot of other larger facilities might have departments. And because of that, One of the challenges from a divergent standpoint is that in a very small institution, it gets hard, if not impossible, to have an objective look at what’s going on with people that you work that closely with. So it can get really awkward as well trying to figure out what’s going on. So what we’ve tried to do with that is we layer in different levels of support within the system. We start with a system level steering committee and diversion. We then have regional controlled substance oversight committees that allow some of those smaller facilities from that region.
And if they suspect something’s going on or reports come or data indicate we should take a look at something, they can have people from that region come in and do an investigation with them instead of them And Karen and I have sat in the same room in a couple of different sites, helping them walk through what to look for and how to look at that a little differently because when you’re a person, it’s really hard to take a look at some of those kinds of things. So that’s how we’ve tried to lay that out. So that you don’t have to do that in a vacuum in your own very small organization.
Terri
Yeah. That’s great. Yeah. For I mean, first, I think there’s a difference you refer to your hospital as how many square miles you cover, which I have not heard before. So I think that’s cute. I like that. But make sure it happens all the time when it when rural the systems tell, you know, how many beds they have. It’s not beds anymore at Square Miles.
Tom
Square Miles. That that’s how we think about this.
Terri
Yeah. But, you know, you do bring up a good point, and that’s the biases, which we see at every facility. Right? I don’t care how big or how small that care area leader will have biases toward their stuff because they’ve been working with it. But now you layer on top of that know, in a larger hospital, it’s like, well, you’re not gonna look at that. You know, we should be looking at that for you because we don’t have the bias. We we don’t know this person. We’re outside of your department. But if it’s a small hospital, who is that person outside of the department that is supposed to take over? So you’ve filled that into that. That’s great. Karen, did you have anything you wanted to add on top?
Carin
Yeah. I think that one of the things that I noticed that you just said Terry was key. It was that, you know, Tom and I generally don’t have to tell our leaders in the smaller facilities that they shouldn’t be looking at each other. Generally, what they’ll do is they’ll reach out to us through the infrastructure that we’ve set up to ask us to come in because they don’t generally want to investigate each other. These are people who just sat together at Easter dinner. In these tiny little communities of 400, 600, 800 people, and they all work together. They don’t they really generally don’t want to invest in each other. So they’ll ask their regional group to ask myself or Tom to come out and take a look so that they don’t have to And it’s I think it’s a very mature way of looking at how to take care of their own within their small towns and their tiny communities where everyone is either they know each other or they’re related to each other.
So I appreciate the fact that they’re acutely, like, self aware in that way.
Terri
Yeah. You know, that’s an important point because people in the larger hospitals, those managers don’t wanna be doing it either. They’re like, nope. I don’t wanna be in this. This is awkward. Either either they don’t wanna be doing it because, you know, these are their people and, you know, friends to some extent, colleagues, but, also, they’re not trained. They don’t feel comfortable having to approach it. What if I’m, you know, accusing them of something that’s not right? But I think that their leadership has the expectation that this is part of your managing responsibilities. So these managers might not really be different. It’s just that in a larger institution, they’re not really given what they feel is that choice and told, no. You shouldn’t be doing this and in the middle of this. And so we’re going to take care of it for you. That does not put in place for them.
So perhaps that’s the I’m sure you’re right. The Easter dinner thing, and you’re sitting across the table, that probably happens more. In a smaller setting, you’re more likely to run into them at the grocery store or be related to somebody or married through somebody or, you know, what have you. But I still don’t think I still think that the managers don’t wanna be doing it. They’re just not given the tools, the permission to hand it off and say, mm-mm. I’m not touching this. You know, somebody else needs to do it.
Tom
Yeah. Terry, I think what I hear you getting at is that everybody needs some help at different times. How and where you provide that help as a hospital as a system can vary, and it’s okay to have some way to get people out of these conflicted areas. I mean, it’s part of being a leader. You have to be involved. You have to understand how to do that. But you don’t have to do alone. You can find ways to be helped out by a committee, by a group, by another team, by somebody in another hospital within your system. I think that’s an important point.
Terri
Yeah. Agreed. Agreed. Alright. Are there things that you see differently or do differently in these smaller communities to keep patients and employees safe and address the needs of employees with substance disorder? Do you see it working differently in these smaller communities?
Tom
I would say no. I don’t think it works differently in terms of the overall structure and process. I think that’s the same. I think what’s a little different is just the social context of that. It’s a little as you shrink a group of people, it’s much harder to maintain your anonymity and your privacy and some of those kinds of things get a little bit more difficult. But From a process and procedural standpoint, what we do in terms of no. It’s not HIPAA. Okay.
Carin
I agree with Tom. These types of the beginning of an assessment that dictates whether or not someone help or someone doesn’t, it has to be homogenous. It can’t be different in a critical access hospital than the way it is at a larger facility. If we treated, like, obviously, every case is different, then we’ve had that discussion many times. But I think that the certain criteria need to stay the same just based on, you know, which based on it doesn’t really matter, I guess, based on the size of the hospital or how far away it is from home base. Like, that has to stay the same for the most people.
Terri
Okay. Yeah. Jeff, is there anything that you see your facility or others doing that goes a long way to really keeping your employees safe or getting them help.
Jeff
I think you need to give them I think Tom said it too. You just the atmosphere with that, they need to feel safe that they can talk to somebody. And then being in a smaller community where everybody knows everybody, they have to be safe enough to. Ask help and then seek the help and then hopefully be treated, go through therapy, what have you. But to get out into the community. And — Mhmm. That’s probably one of the bigger challenges that if somebody’s going to see one of the doctors or what have you, that is pretty much kept between patient and the provider, and they get their help. And the other thing though is they talk to, one of their friends or something that can get around in the community as well if that gets out. At the hospital level, at least giving them a safe environment to come forward.
Terri
Yeah. And, again, I think that you know, across the board, how do you develop that culture where somebody can feel comfortable raising their hand and saying I have a problem. That it doesn’t mean an automatic necessarily loss of license, loss of job, what have you, and keep that confidentiality, which should be across the board. Right? For everybody, it doesn’t matter where you come from. It should be kept confidential. I guess the difference is that if somebody if word does get out, it’s in a smaller community more likely that the entire community is gonna figure out, find this out as opposed to just your own little circle. Right? The You’ve got a few little people opening their mouths, and that can make a difference. I know that at a very you have a very robust work, reintegration, reentry type of a program, and you try to work with them depending on the circumstances, of course.
Do you do you have something like that at Hillsdale as well to try to get them back into the workplace?
Jeff
They will go through a couple programs that HR would have for them. They would depending on If they are licensed or not, going through the health professional recovery program and then working along with that. And then we do have some additional saves through the hospital that they’ve got set up that they can talk to. And then there’s also a anonymous line that If they wanna keep it totally out of the hospital, they can call in, seek professional help that way. As that might be from their home, from the car, wherever they feel comfortable, and the hospital takes care of that as well.
Terri
You said something interesting, Joe, if they’re licensed. And I think that we’ve we I know I focus more on the professionals who are licensed and that’s what all of our monitoring and surveillance surrounds. Right? If they have access to controlled substances, then you’re just looking to make sure everything is okay, and that’s how we monitor. But there obviously are employees that work for our hospitals that aren’t licensed and don’t probably have access or should have access to medications, right, unless somebody’s laying things around, or they’re getting things out of the waste buckets because they’re not being wasted appropriately, and they’re still retrievable. So we do have to think about that, and I wonder if that’s a difference maybe in a rural setting is that you’re more honed in on those people just watching you just see differences in behaviors because you know these people, and it’s a smaller setting.
Terri
And so maybe there are some unlicensed that are going into treatment because they’ve been identified community? Do you guys have any thoughts on that? Are you seeing any of that?
Jeff
We’ve got a little of between the community and the workforce, you’ve got a little of every that, everything there. And it Other than they wouldn’t enroll in a health professional recovery program, but the other resources are available for them for help as well.
Terri
Yeah. Okay. Are there any cases that any of you can share that would simplify an approach that worked in a rural setting that was perhaps different than what may have been in a larger institution or would have worked as well, maybe in a larger institution, just a different approach.
Tom
I wouldn’t say it’s a different approach, but we have had to utilize our system level teams to help smaller facilities. So there’s off person in a given area there’s no one else to really do that investigation. So we’ve had to we’ve had to bring some folks and bring teams in to help support those smaller facilities. So that I guess if you wanna it was a different well, it is because, I guess, there’s more of an outside version wherein the larger facility, we just bring people from another area or another department, but they’re still within that overall hospital. Yeah. But there’s not there’s really not another area to bring them from. So you have to do it a little bit differently by bringing other people into the organization, which, you know, certainly can create some interesting conversations as much people that aren’t normally there show up to start doing some audits and some work, then that, of course, creates a little bit of conversation.
Terri
Yeah. What about the fact, so let’s say that somebody you know, either they are found out or they ask for help, and then they disappear. Right? Because they’re in recovery, and they’re going through their program. And then in a larger community, that person doesn’t have to they wanna keep working. They don’t have to come back to the institution where they were at, whether that institution has a reentry program and would allow them or not, they can choose to go somewhere else and start fresh, so to speak. But in these smaller communities, if they wanna get back, to active working with their license. I imagine their choices are slimmer. And the chances of them having to go back to that same institution if they wanna keep working are much higher So they’ve disappeared, and we kept it all quiet, and now they’re back. How does the is that just one of those things that are people typically pretty honest?
And then the institution uses that to their advantage because they’re saying, hey. We’re a place that will welcome you back after you’ve, you know, healed and gone through their recovery or do you find that nobody kinda talks about it, and that’s where rumors start going? Or do you have any sense? I’m I’m sure, again, situation is different. But in general, do you see it kinda handled one way versus the other in those cases?
Carin
I think that Avera, as the facility that John that Tom and I work for, the facility that we work for, the organization has done a lot of work to reduce some of the stigma surrounding substances disorder. It’s not something that we celebrate at any point, but at the same time, some of our systems are so far away from the punitive stuff from 30, 4 you know, even 20 years ago. So the more work we do to reduce that stigma and I know I’m gonna sound like I’m so boxing here. But this is the public health study. Yeah. Studio. It’s part of me. But the more that we reduce that stigma in smaller communities, the more people are, like, usually more willing to talk about their experiences. And if I came across someone like Tom Johnson, for example, who was a successful executive, that has been through the health professionals assistance program, and he’s willing to talk about that, not maybe in a public setting, but with a little less fear, then chances are more likely that I’ll seek help when I have that problem.
So I think that, like, from a culture standpoint, the more compassionate to your organization can be the better for things like that. And I know that’s a huge, like, a broad answer to — Yeah. To, like, a sweeping answer to your question. But at the same time, you know, what they choose to tell their colleagues and their family members, which sometimes are the same people. In these scenarios is really up to them. We we’re not interested in shaming them or breaking them down in any way she perform. But a lot of times, they come back with some on their own. So it really depends on how they wanna handle it.
Terri
Yeah. Those are good those are good points. Jeff or Tom, did you wanna add anything to that?
Jeff
Well, I think the comment of sometimes their peers, coworkers, and everybody else the smaller the community, we’ve got folks that have pretty much grown up and born in town. Lived in town have worked this is their only gap. And a lot of folks know each other. They have confidences with family and some of their family, they may not wanna talk to about that. But the, I guess, atmosphere As you said, welcoming them back, one is how much they are gonna divulge to whether it their peers, their family, and such. And if they do know things, what I’ve seen in the short time, I’ve been here things seem to work out pretty well.
Terri
Okay.
Tom
Yeah. What I would add is over the years, I think as people have you’re right. If you’re kind of in that one small community, a lot of times people move on, particularly if they’ve had an actual diversion issue or they’ve been dismissed from an organization, they’ll move on. They may still live in the community, but they’ll choose to commute to a different facility for a fresh start. And and that’s probably been most common just from their own recovery and process. And, you know, to be clear, I haven’t been through the Sorry. You know, recovery program, but, you know, it was just to make sure that — But Karen’s right. I am pretty open about the things and different challenges of and people choose how to relate that information back and. Mhmm. Again, that’s part of their own recovery and their own process.
Terri
Yeah. Yeah. Oh, you’re right. I mean, it’s a good point, Karen. Comes down to that stigma piece of it. Right? And that’s something that we’re that’s part of the reason for these podcasts to get that information out and humanize it so that it’s doesn’t it’s not the I can’t believe that, you know, it’s like, oh, my. It’s more of that compassion and kinda imagine what they’ve been going through, you know, that they have found himself in this place. And and I I don’t know. I have to think that maybe it is easier to create that culture of compassion and remove some of those stigmas at a smaller place, but maybe that’s just naive in thinking that. Like, you know, you’re all a a family and you’re a little bit more understanding. I don’t know. Maybe that’s not accurate either, but we do have to continue reduce that.
And it you’re right. It’s part of their healing process that they’re gonna have to deal with, you know, what is this gonna look like on the other side, and so what are ready to get to that point, then that’s something that they start up to assessing and may include moving or driving someplace else. So, again, it’s really the same thing that everyone has to deal with. When they’re going through that recovery portion of it. So it sounds like other than everybody maybe being related to everybody and sitting across the table at Easter, there really are not a ton of differences in how it should be handled. If you have an effective program, you keep all the same pieces in place, try to rebuild the biases. Do it with compassion, welcome them back if they, you know, choose to come back and they have gone through that recovery successfully depending on the situation.
And keep everything confidential. And it’s up to them, but it’s the same basic principles. Okay. Alright. Anything any of you wanna add before we wrap it up?
Carin
I grew up in one of those tiny little towns with a population of. So I think I I can safely say that I understand what the gossip now looks like. Yeah. You had kind of touched on are we talking about this or are we not talking about this? I think that it’s a lot different now than it was then. And you know, Tom and I have a philosophy of making this the villages problem instead of the individuals problem. And I And I think that to an extent that works really well for us, I’m not sure how it works, like, with Jeff’s facility, but For us, the easier we come down on this, like and the more we treat substance use disorder as a disorder, The better off we are as these communities grow or shrink or whatever.
Like, the one thing that I wanted to point out is that something that happened with our last critical access case. One has more clout. Because this is a tiny little hospital if for some reason the DEA had to find a small facility like this, there is an entire community of people that would have to travel further for their health care. So From Tom and my perspective sorry, Tom. I don’t need to speak for you. But, like, those hospitals are almost We almost have to protect them and safeguard them even more almost as if they’re just a little more precious because they are quite literally caring for a group in the population of South Dakota that would otherwise not have access to health care that they need. So from a patient care’s perspective, I think it’s really important that we treat those little critical access hospitals in those hometown clinic, like, with kid gloves. Like, we have to be very careful with them because if we don’t protect them from damage to reputations and, you know, DEA finds God forbid.
If we don’t protect them from that, then we have a whole population of people that go without So, I mean, I think from Tom and Mike’s perspective, like, we do kind of treat them a little bit differently. And I think that’s okay because we can’t like, do this in a vacuum meter. So.
Terri
Right. Yeah. I think that’s a really good point, Karen, is it’s not oh, they’re just such a small hospital. We don’t need to devote the resources to them, or we don’t need to have an official diversion program. You know, if something happens, we’ll deal with it. Or it’s so small. We know everybody. It would be so clear we’ll jump on it if we need to it’s almost the opposite. They you need to be very focused because, number. You wouldn’t be able to afford any of the fines, not that any facilities these days can either. But and if the ramifications were to shut them down, that would be devastating in the community. So we do need to put some time and resources from the parent facility or however it is you’re gonna at work. But rather than ignore, they actually might need more attention to make sure that they’re protected.
Terri
It’s an interesting perspective. Yeah. Okay. Well, I wanna thank all of you for your time. I know you’re busy as as all of our pharmacy leaders and employees are. So I will let you go, but thank you very much for sharing your experiences in your rural hospitals with the rest of the community.
