Kimberly Elliott is director of social services for Citizens Memorial Hospital in Bolivar, also known as CMH. They serve an eight-county area, including Benton, St. Clair, Hickory, Polk, Cedar, Dade, Dallas and parts of northern Greene County.
She’s seen the challenges of rural healthcare firsthand. The March of Dimes has labeled 51% of Missouri’s counties as maternal healthcare deserts; 41% of our counties have no birthing units. That leaves fewer hospitals serving larger more widespread populations, and rural communities often face issues of poverty, mental health issues and substance abuse with fewer resources to help their residents overcome those issues. While expectant moms in rural communities can face real clinical challenges, non-clinical factors can have a huge impact. It's why Elliott does what she does.
“When I first went into healthcare, I'm like, this is not social work, this is discharge planning and just getting people out the door. I can honestly say now that my teams do social work,” she said.
While CMH’s medical professionals take care of their patients’ health needs, including at the hospital’s Birth Place, Elliott manages a team of social workers that make sure their patient’s non-clinical needs are being addressed too. Elliott said her team has to be proactive. They do a screening of every new OB-GYN patient to determine their social needs.
“It's really getting with them, making them feel comfortable and hoping they'll open up," said Elliott. "You're still going to miss people regardless. It's not everybody is comfortable or confident in telling you the things they need, but the hope is that they will.”
Making sure mom can get to all of her appointments is their first concern, which is a challenge in a service area that spans hundreds of miles with relatively high rates of poverty.
“There is a lack of resources available within our counties that creates concern for our pregnant women. Usually that comes with transportation. It's shameful if you're not able to get to and from where you need to go," she said. "Also, gas is expensive. Cars are expensive. And keep in mind, eight counties is a large area, so you could be coming from an hour and away and not able to get there. Well, then you have this no show, no show, no show, and it's all because you don't have transportation.”
Those no shows can look disrespectful when they are just trying to hide the facts of life. They can add up, and medical professionals see every follow-up appointment as essential, especially postpartum. Missouri’s medical leaders say that most preventable maternal deaths happen postpartum. Elliott and the team at CMH know how valuable each appointment is.
"Medicaid will provide transportation to and from appointments. I will say it's not always reliable, so we do have other programs that do that. Our ToRCH program also provides, transportation," she said. "We utilize the OATS bus. We also utilize other resources. We have a program called Club 1982, which is through CMH. If somebody needs transportation, we're going to figure it out.”
The ToRCH program Elliott mentions stands for the Transformation of Rural Community Health program, designed to help address the social needs of Medicaid healthcare recipients. It's just one of many programs tied to Medicaid that CMH and other rural hospitals make use of.
As Elliott describes it, her team and the clinical staff at CMH have to be nimble to meet the challenges of serving a rural under resourced population. They're relying on whatever partners and options are available, while keeping the hospital and its resources at the center of care, and doing everything they can to meet patients where they are.
That means utilizing CMH’s Mobile Integrated Health program, a community paramedic and lactation specialist that can visit patients in their home and a system to visit with a paramedic remotely.
Elliott said her team works to connect moms with all the resources they need to take care of themselves and their new baby.
“WIC is probably the biggest one, food stamps, obviously. Substance use treatment if it's needed. Breast pumps, Safe sleeping. So, like a bassinet or a crib or a playpen. Food pantry," she said. "I mean, it's honestly endless, but those are the bigger things.
"We also can provide through our ToRCH program, for women who are on Medicaid and in the Polk County area, home modifications. We can also do nutritional counseling. So, if you're a mom who's diabetic. Because that happens rather regularly, they can have nutritional counseling and then medically tailored meals due to their diabetes."
The sorts of resources any mom from any community may need but made more complicated by the relatively vast rural setting.
“If they're from a different county, they're going to get, you know, maternity care here, but then they're going to have to go to the other county to get their benefits or food stamps or food pantry, whatever that is. It could be multiple stops. Across our eight counties, the things that are available and able to be provided for our patients are greatly different. Our OB social worker, you know, that's what she specializes in. So, she is very good at keeping her resources known in all eight counties because she does it on a daily basis," said Elliott.
It is the sort of extra effort that is life-changing for rural patients and hospitals. That effort can only accomplish so much without funding. Many of the programs CMH and hospitals across the state rely on are funded by Medicaid. When Elliott talks about the impact her team has and the resources it takes to serve her community, she returns to a sentiment shared by many rural hospitals and everyone I spoke to on the topic of maternal healthcare.
“I guess I'm kind of scared in regard to Medicaid cuts because we cannot cut that program anymore. We're already not helping enough people as is. We need to help more,” she said.
And Elliott and her team are helping everyone they can at CMH, developing programs and partnerships and utilizing resources that overcome some of the challenges facing expecting mothers and new moms in the rural Ozarks. It requires building relationships and community and building trust with patients. Not that different from healthcare anywhere, but just a bit more complicated.
As the social and economic realities of rural communities continue to change and modern medicine and social work continues to evolve, hospitals like CMH will be at the forefront of navigating those challenges, delivering care and delivering the next generation in some of the sparsest and most under-resourced areas of our state.
Nick Burasco and Dax Bedell provided production support for this story.
Find more in our Sense of Community series at this link, and view companion documentaries from Ozarks Public Television at OPTV.org.