Minnesota’s Groundbreaking Solution to Rural Obstetrical Care Gaps

In December, leaders at the Eagan-based Blue Cross Blue Shield of Minnesota announced a groundbreaking initiative to support rural healthcare.

In rural Minnesota, just as in rural areas of many states, obstetrical care involves huge issues. For example, due in part to longer travel times for emergency care, expecting mothers in rural areas are 9 percent more likely to die or experience life-threating complications during childbirth than those in urban areas. And even when women about to deliver are able to access care safely, it often involves travel across long distances, and hardship and inconvenience for pregnant women and their families.

Now, in a first in Minnesota, the largest health plan based in that state, Blue Cross and Blue Shield of Minnesota, is funding and supporting a birthing simulator and training program that could make all the difference for expecting women in rural areas across the state. The initiative was announced in mid-December via press release.

The Dec. 15 press release began thus: “Blue Cross and Blue Shield of Minnesota (Blue Cross) today announced that it has funded investments in technology and practice support resources for Community Memorial Hospital (CMH) in Cloquet, Minnesota [Cloquet is located about 20 miles southwest of Duluth, in the far northeast of the state], allowing new training capabilities to optimize labor and delivery care for patients throughout the state. The Operative Experience Labor and Delivery Suite, which was recently installed at CMH, provides a life-like simulation for all types of obstetric care, from routine procedures to emergency interventions. The first to be implemented in Minnesota, this obstetrics simulator will be used to provide additional training opportunities for rural providers at CMH and other hospitals across the state, beginning in 2022. Because labor and delivery skills require constant repetition, many rural hospitals with only a small number of births each year must look for other opportunities to keep skills and knowledge sharp and up-to-date. Too often, this challenge for rural hospitals leads to obstetric department closures and longer travel times for patients.”

The press release noted that, “According to research from the University of Minnesota, expectant mothers living in rural areas are nine percent more likely to die or experience life-threatening complications during childbirth, compared to those living in an urban area. This unfortunate reality is due in part to the fact that more than half of rural counties across the country have no hospitals that provide routine labor and delivery services, which means patients must travel much further to receive this necessary care.”

Further, “CMH is a critical access hospital – a designation from the Centers for Medicare and Medicaid Services (CMS) for hospitals in rural areas which serve patients who would otherwise need to travel a long distance for emergency care. Located about 25 miles southwest of Duluth, CMH serves a large geographical area, including the Fond du Lac Reservation, which has its tribal headquarters in Cloquet.”

The press release quoted Rick Breuer, CEO of CMH, as stating that, "For a critical access hospital like ours, it's important that our physicians, nurses and support staff are trained appropriately for all types of labor and delivery care – from vaginal deliveries and c-sections to emergency hysterectomies. We know there are disparities in health outcomes in rural areas and for minority populations, and we hope these training tools can aid us in efforts to eliminate those disparities as well."

Meanwhile, the press release noted that, “In addition to providing training for its own health care professionals, CMH will make the obstetrics simulator available to other rural providers across the state who are facing similar challenges.” And it quoted Karen Amezcua, BCBSMN’s senior director of provider partnerships, as saying that "Long-distance travel is commonly cited as one of the biggest barriers to health care for our members. As we continuously work to ensure we are providing access to the full continuum of care across our network, it's crucial that rural area hospitals maintain a high level of skill and confidence in obstetrics. Blue Cross anticipates that our investment in this state-of-the-art technology will improve the sustainability of high-quality care for expectant mothers by eliminating barriers that lead to worse health outcomes."

Earlier this month, CMH’s Breuer and BCBSMN’s Amezcua spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding this innovative initiative. Below are excerpts from that interview.

Can you share with us about the origin of this innovative program?

Rick Breuer: About five years ago now, our local family doc group which was still separate from us organizationally, we’ve since merged. But they came and told me they were going to have to stop doing OB. We’re a rural community, but we still believe we should be offering obstetrics as a core service. They didn’t want to try to recruit more docs. We were able to recruit five physicians to do full-scope obstetrics. But even the most experienced ones—you still need to be proctored, monitored. When you have a low-birth-volume hospital, it takes a while just to get docs through proctoring. We thought we had set up a solution; a nearby tertiary care hospital told us that they would help us and do the proctoring. But then they changed their minds. And our own proctoring was going painfully slowly.

And we found that rurals were the only ones helping each other out. All the big systems stood up at a conference and said, we’ll help. But when push came to shove, every hospital had reasons why they couldn’t take rural docs and nurses in and immerse them. So we looked at all different types of opportunities, and they all fell through. So our workgroup finally pivoted to simulation. But the state-of-the-art equipment was far too expensive. So we considered charging fees to users to cover costs. So we were modeling out, but said, maybe someone could fund this as a grant opportunity.

The costs—there are a few different ones. First, getting all the equipment and supplies, but then the cost of your own staff using trainers, and training how to be a trainer. And if you’re practicing a c-section, you’re cutting into something. Medical and surgical equipment for the full gamut of obstetrics, from the straightforward vaginal delivery to post-partum hemorrhaging, breach birth, etc. You can do anything but to simulate twins or triplets. But through the suite of products we’ve acquired, you can simulate every other type of circumstance.

This required collaboration; all the rural partners agreed this is the problem for everyone. There are new docs and nurses coming in. But a group of five delivering 80 babies a year, with five c-sections, that’s not enough practice for the docs. Some studies have shown for med students that supplementing live deliveries with simulated deliveries actually is superior, because you can simulate all sorts of deliveries. So we thought, what if we created something that could be used statewide by the rurals?

So that was what we were chasing, in the fall of 2020, when the pandemic was really hitting us. And in the previous six months, we had reset the relationship with Blue Cross. We had moved away from an adversarial, fighting-over-contracts, relationship, to a reset towards partnership. And we said, how can both parties reset the relationship, and partner together? And in contract talks, the BCBSMN people said, how can we help? And I tossed this out of left field. And I said, BCBSMN has a huge footprint across rural Minnesota.

And I’ve never seen a grant process move so quickly; our contacts got back to us within a week, asking us to submit an application. And less than a month later, my contact called me to say BC was willing to fund the full suite of five different models that covers all the different medical and surgical situations, and the full suite of equipment. And before that day was out, I had contacted all the stakeholders here, telling our folks, we’ll be able to start doing this, and doing it right. So we started speaking with all our rural associations, having conversations with the local medical school, two nursing schools.

We had a demo last spring to make sure the product we had identified was the right product. And I stood there and watched a simulated baby be born many times. And every single person was amazed at how realistic it was; even people who had trained with other simulators told us this was light years ahead. We had an individual from another medical community, asking if he could come up with his chief of obstetrics; they had just been wondering whether they could keep OB going, because of not having enough time at the table. So this was the solution—for doctors and nurses.

A lot of people come from organizations with fewer than 100 live deliveries a year; and it’s hard to keep people up on their skills with that; and you’re hoping it won’t be an abnormal delivery. Here, you can do a full day of nothing but c-sections or shoulder dystocia, or breach birth, a hand coming out. I have a doc here who’s been delivering babies for 20 years, has never had to do an emergency hysterectomy, but thanks to this simulator, was able to practice. And now we can practice breach technique; he had only ever delivered one breach baby. Super-valuable to practice the less-common procedures. And so valuable for teams. And we’ve trained all of our staff with this. Our folks were kind of the guinea pigs. And seeing our staff work as a team—the nurses and doctor—to do the right things at the right time. This is such sophisticated equipment. The trainer can make things happen with the simulated mom and baby. The team can respond. Routine delivery or red-light c-section. It’s tremendous. And I’m a rural Minnesota kid, and I care about all the parts of the state, and if this can help people in all parts of the state—babies are still being born in ERs. And those moms in rural areas deserve to deliver safely. And the farther a mom has to travel, the worse the outcomes are; we know that from the statistics. So if we can preserve safe obstetrics closer to home, that’s great, as well as preparing clinicians to practice in rural areas.

Tell me about the Cloquet community and your service area?

Our community numbers about 11,500 people; our service area is about 35,000, most of Carleton County. Critical-access hospital, 25 inpatient beds. We’ve got an attached 44-bed nursing home, primary care. We’re on the larger side of critical access hospitals in MN, usually thought of as the fourth-largest. We have 12 family medicine providers, docs and nurse practitioners. And surgical—we 11 surgeons. We employee 500 individuals. Physicians are employed.

We have one boarded OB/gyn. And that’s one of the challenges for rural communities. Many rural communities can’t support even one OB/gyn. This individual, she mostly works in women’s health, maternal health, assists in complicated deliveries. Most rural communities can’t even afford to keep an OB/gyn.

Karen Amezcua: BCBSMN is acutely aware of the differences between rural and urban area delivery. A lack of services being offered and/or trained physicians available to provide services. We know there’s a gap in rural healthcare and need to provide support. We had early on worked with Community Memorial Hospital and other rural hospitals, to look at challenges their facing. Part of it was simply to figure out what was going on, and how we could support them. We needed to hear from them what their particularly communities needed. And when Rick said he’d like to get a grant around the birth simulator, everything he was asking for was completely aligned with our goals for rural health. And what they proposed was really impressive; so we felt this was an initiative that would improve rural health, and that we could reduce life-threatening complications in delivery. And so it was a no-brainer for us. And we’re very excited to see that it’s already in place, and individuals are being trained.

Potentially, you could improve clinician, and especially physician, recruitment, because of this resource, correct?

Breuer: Absolutely, we think it’s a recruiting tool for physicians and nurses. And other communities might support us in this work. We’ve added a research evaluation component; the Office of Rural Health is helping to fund that—where folks will measure the outcomes for this. We do want to be able to come back to the folks at Blue Cross as well as to our communities and be able to demonstrate that this has made people more competent. We think that this can make people more comfortable, knowing there’s an adequate team in rural hospitals. If it can pull these people—let’s face it, if they’re going into family medicine, it’s the broadest specialty. And medical schools are talking about bringing in first- and second-year students. Traditionally, you wouldn’t get to do a delivery until third year. But by providing that opportunity, individuals … They really have to be able to stand on their own in these communities; you don’t have a big team that rushes in. Practitioners have to be able to handle a broader array of procedures and scenarios.

The intensity of the training, advantages?

In a live delivery, your main goal is a healthy mom and healthy baby. Here, you can stop at every point along the way, you can debrief and reset and go again. And all that is an important part of the training. There’s amniotic fluid, there’s blood, there’ urine. The postpartum hemorrhage model, you control the rate of bleeding. And there are several specific surgical techniques that will address and fix postpartum hemorrhage. The equipment functions as a human body will, to the point where one of the devices is a balloon device, to the point where when people demonstrate, they bring that equipment out, because it works as it works on a human. And you obviously can’t find women in labor to try this out on. It’s so lifelike, and that all adds to that experience. Our folks have acknowledged, their hearts race as though it’s the real thing. You get the intensity, but it’s intentionally an educational experience. A safe space to learn. It’s going to take a while for us to fully optimize it. We’ve got all the collateral materials ready. We’re getting to the other side of the pandemic, so we think we’ll be ready to open the doors. And we’ll want to talk to others to see how this could be replicated in other parts of the country. And the same company that manufacturers the OB equipment, makes trauma equipment. And that would be another great conversation to have with someone, around how we could collaborate around bringing more resources to rural providers; but this will keep us busy for a while. We’re excited about what this can mean. We’ve got a long waiting list already.

Are you aware of any other health plan funding something like this?

Amezcua: I’m not aware of others. But we do have several initiatives around maternity care. And we’re going to do a program with Everyday Miracles and Wellshare International to expand doula and community healthcare. So we’ve funded scholarships to recruit and retain and certify around 45 BIPOC doulas. So we really want to partner with providers in different communities; the needs are all different.

Breuer: We can’t thank Blue Cross enough. Also, the Minnesota Office of Rural Health is providing us with some ongoing funding, particularly for nurse staffing.