Hub-and-Spoke Healthcare
Alaska Regional’s proximity to Merrill Field in Anchorage allows fixed-wing aircraft to taxi to the hospital doors, saving precious time for patients in need of care.

Alaska Regional Hospital

Hub-and-Spoke Healthcare
Alaska Regional’s proximity to Merrill Field in Anchorage allows fixed-wing aircraft to taxi to the hospital doors, saving precious time for patients in need of care.

Alaska Regional Hospital

Addressing service gaps in rural Alaska
By Vanessa Orr

reak your leg in Anchorage and chances are you’ll spend a few hours in one of the city’s three main hospitals—Alaska Regional Hospital, Providence Medical Center, or the Alaska Native Medical Center. Break it out in the Bush, and you may find yourself having to fly to a larger city to get specialized care, especially if there are complications.

While there are many advantages to living in Alaska’s remote areas, one of the biggest drawbacks to rural living is the lack of access to specialized healthcare.

“Urban areas by definition are defined as a large population that can support a more robust healthcare infrastructure; rural areas do not have the same advantages,” explains Heidi Hedberg, chief of Rural and Community Health Systems, Alaska State Office of Rural Health.

While a number of villages have community health aides, behavioral health aides, and dental health aides, as well as visits from public health nurses, those who require acute or advanced care often find themselves having to leave the community to get the help they need.

“Access to healthcare is an ongoing concern in rural communities, as are workforce shortages and high healthcare costs,” says Hedberg. “In general, individuals living in rural communities may receive some healthcare services, but if they need additional services, they would need to travel to a hub community.”

Alaska has a hub-and-spoke healthcare system, according to Hedberg, with hub communities typically containing a critical access hospital to serve the surrounding villages. There are fourteen critical access hospitals across the state in Cordova, Ketchikan, Petersburg, Kodiak, Seward, Valdez, Sitka, and Homer, including Alaska Native tribal hospitals in Dillingham, Kotzebue, Sitka, Nome, Utqiaġvik, and Wrangell.

Approximately 150,000 Alaska Natives use the Alaska Tribal Health System, which operates 180 small community primary care centers, more than two dozen mid-level care centers, six regional hospitals, and the Alaska Native Medical Center in Anchorage.

If patients need more advanced care than a primary or regional care center or hub hospital can offer, they may travel to Alaska’s larger cities. Some people living in Southeast communities also choose to travel to Washington State for healthcare services because it is closer than many Alaska facilities.

In Case of Emergency
So what happens when a person suffers a traumatic injury or needs immediate medical care for an acute issue, such as the onset of stroke?

In many cases, patients need to be transported to larger general acute care hospitals, such as those located in Anchorage, Juneau, Fairbanks, or Sitka.

“When a patient comes into a smaller clinic or facility, they are first assessed by [our] staff to determine whether it is appropriate for them to stay in the community or if the patient needs to be transferred to a larger hospital,” explains Rob Stantus, assistant administrator at Alaska Regional Hospital. “In most cases, the person would be transported by air due to the state’s infrastructure. We probably fly more patients than we would otherwise do if we were located in the Lower 48, simply because in some places it’s the only mode of transportation.”

“A lot depends on whether or not the patient’s condition is time-sensitive, and while we always err on the side of caution, we do consider a number of factors because of the expense involved in moving people by air ambulance.”
—Rob Stantus, Assistant Administrator, Alaska Regional Hospital
Though the hospital partners with Guardian Flight, it has relationships with all of the air ambulance operations in Alaska and receives patients from all over the state. This also includes accepting patients brought in by the National Guard and the Coast Guard. The hospital’s Patient Transport Center coordinates the flights, as well as connects Alaska Regional physicians with the physicians onsite. The air ambulance provides clinical and aviation staff.

“Whether a person comes in on an air ambulance or may take a commercial flight depends on what’s going on with the patient,” says Stantus. “There’s a risk anytime you move a patient, whether by air ambulance or by a ground ambulance, between hospitals. It may be determined that a person with a less serious medical condition or a planned surgery can take a commercial flight; on the other hand, someone suffering a heart attack, stroke, or trauma may need to be transported by air ambulance because it’s quicker and has medical attendants on the flight.

“A lot depends on whether or not the patient’s condition is time-sensitive, and while we always err on the side of caution, we do consider a number of factors because of the expense involved in moving people by air ambulance,” he adds.

Telehealth Gaining in Popularity
In order to provide people living in remote areas with the type of care they receive in Alaska’s urban centers, a number of providers are exploring telehealth options. Telehealth programs may include live video conferencing, store and forward, remote patient monitoring, and/or mobile health.

“Telehealth is one of those areas that we are actively working on to address access to healthcare and workforce shortages, but we have a long way to go,” says Hedberg. “Connectivity can be spotty in rural communities, and better policies need to be developed to help rural communities understand how to engage in telehealth and [obtain] reimbursement from insurances companies.

“In addition, providers from the Lower 48 using telehealth to provide services in Alaska must be licensed in Alaska, which can take time,” she continues. “Telehealth contracts also need to be set up so they are not cost prohibitive.”

According to Hedberg, the Alaska Native Tribal Health Consortium has a robust telehealth program, and the Alaska State Office of Rural Health is currently working with nontribal rural communities to develop similar capabilities. It is supporting several telehealth pilot programs in Petersburg that can be replicated in other rural communities, with plans for Petersburg Medical Center to launch tele-psychiatry services at the end of February.

Alaska Regional has also been growing its telehealth program and currently provides telestroke and behavioral medicine programs to Central Peninsula Hospital in Soldotna, with plans to add similar programs in the Mat-Su Valley in the near future.

“Telehealth has been around awhile and it’s been gaining in popularity in the last couple of years, in part because of technology improvements and also a willingness by providers to participate in the program,” says Stantus. “The reimbursement model is also becoming more palatable for providers and patients.”

Through its telestroke program, Alaska Regional is able to triage patients when time is of the essence. “We partner with a neurology group affiliated with one of our sister hospitals in Colorado that provides dedicated, board-certified neurologists 24/7 to respond to patients in the ER who have stroke-like symptoms,” explains Stantus. “Within ten minutes, a neurologist is on camera with a Central Peninsula physician to help determine whether that patient can receive a clot-busting drug or may need to be transferred to Anchorage or another destination.

“Stroke is so time sensitive that this type of early intervention is extremely beneficial; the sooner symptoms resolve, the less chance of massive, debilitating long-term effects,” Stantus adds.

The benefit of telemedicine programs is that they allow smaller hospitals, which could never afford to keep a specialist on staff, to provide patients with the same level of expertise that they would receive in Alaska’s larger cities.

“There’s just not enough business for smaller hospitals to be able to keep a neurologist on staff; they may only see ten patients who need these services a month,” says Stantus. “But through telehealth, these specialists can treat those ten patients, plus another twenty patients at a different hospital, plus another twenty somewhere else; when you reach critical mass, it becomes worth it to employ a specialist.”

Alaska Regional also partners with social workers in Salt Lake City to provide behavioral health telehealth services. “In the past, social workers assessed patients in crisis in the ER, but not all communities have these professionals available, or their ERs may not be staffed on nights or weekends,” says Stantus, adding that via telehealth social workers are available 24/7.

“While this does solve some issues, it doesn’t solve them all,” he adds. “Oftentimes resources are so strapped in Alaska—such as inpatient psychiatric beds—that even if a patient receives an assessment in a timely manner, there may not be a bed available. We can at least provide guidance to ER physicians on how to manage the patient and recommend resources available in the community.”

All of the telehealth professionals who work for Alaska Regional, including the social workers and neurologists, are vetted through their credentialing process and are licensed to practice in the state of Alaska.

In the future, Stantus sees larger hospitals providing telehealth services beyond acute care, possibly offering speech pathology or diabetes education services to the communities that need them.

“We have the resources in Anchorage to do this, and if we can connect via technology, patients will no longer have to travel for these services,” he says. “Anytime you can keep people local, it benefits the patient, their family, and the local community hospital as well.”

One of the biggest advantages to telehealth is that as technology advances and becomes more user-friendly and less expensive it also becomes easier for medical facilities to invest in such technology.

“Before, having a security-compliant, bi-directional video connection required an investment in expensive telemedicine devices,” says Stantus. “Now, you can call someone on your iPhone or computer and have an online session. You no longer need as much bandwidth, and internet in most communities has gotten better, which makes it much easier to create a cost-effective platform that is HIPAA compliant and secure.”

There are still some drawbacks to using this technology in rural areas, however. While the telehealth system is robust, certain health conditions still require that clinics or remote hospitals have other diagnostic tools.

“It sounds great to have telestroke services at every clinic in Alaska, but if a facility doesn’t have a CT scanner to help diagnose a patient, it doesn’t make sense,” says Stantus. “This is why we have a community outreach liaison that goes out and visits the communities and assesses their needs. It’s great to have all of these offerings that you think everyone could use, but you have to make sure that it’s what they want.”

Because this is an emerging field, Stantus adds that hospitals need to be able to show insurance companies as well as administrators that this technology provides value-added services. In its telestroke program, for example, metrics include reduced door-to-needle times. The hospital is also working with rural facilities to find “pain points”—service areas such as diabetes education or wound management where they may have trouble with recruiting or staffing and where telehealth may be a viable option.

“Healthcare is always going to be a challenge in rural areas—not just in Alaska, but anywhere in the country,” says Stantus. “There are a lot of advantages to not living in a crowded area, but one thing you give up is access. Through the use of air ambulance and telemedicine, we’re trying to bridge that gap.”