Ballad looks to consolidation to solve problem of too few patients, not enough staff

At Mountain View Regional Hospital, just two miles away, only three patients have been admitted.

Later that morning, one of the nurses there pulls the chief nursing officer aside to tell him she’s very worried about her job. They have so few patients. They have so few nurses, too, he tells her. She’ll have a job, but it most likely won’t be at Mountain View.

“We really have enough staff to run one hospital in Wise County and we’re running three. That’s the challenge,” said Mitch Kennedy, who recently was promoted from chief nursing officer to chief operating officer of the Wise and Dickenson hospitals.

A week later, Ballad Health announced it will close Mountain View’s medical and critical care units and shut down its emergency room. The patients, Ballad said, can be better cared for safely at Norton Community and Lonesome Pine Hospital, 12 miles away in Big Stone Gap.

This is a start to many changes to come in Wise County, as Ballad seeks to modernize a system that has many empty hospital beds, and yet, still too little access to health care.

Staying solvent

Ballad took over ownership of the three hospitals last year following the merger of Wellmont Health System and Mountain States Health Alliance, the two predominant hospital systems in Virginia’s coalfields and Tennessee’s Tri-Cities.

It wasn’t until the veil of competition was lifted that Norton CEO Mark Leonard, who now manages the Wise and Dickenson counties market, could see what Wellmont had done to keep Mountain View afloat.

Very sick patients who had checked into Lonesome Pine’s emergency room were loaded into an ambulance, driven 12 miles over a mountain and admitted to Mountain View’s intensive care unit. One surgical team traveled between the two Wellmont hospitals, leaving moms in labor especially vulnerable should they require an emergency cesarean section, he said.

To be fair, he said, Mountain States also had done all it could to keep its patients out of Wellmont’s grasp, often sending them from Norton Community 70 miles away to Johnson City, Tennessee, when the care they needed might have been only two miles away at Mountain View.

The hospitals focused on staying solvent, while Norton and Wise County residents became among the least healthy people not only in Virginia, but in the nation.

Three hospitals were of little help when there weren’t enough doctors and nurses to keep units open.

Few medical options existed to help people with disabilities and chronic illnesses. Specialty and primary care were limited, and behavioral health care nearly nonexistent. But pain pills were abundant.

During the height of the competition, Norton became an epicenter in the opioid epidemic, with more pills prescribed per capita than elsewhere in the nation, according to a Washington Post analysis of a recently released Drug Enforcement Administration database.

Ballad promised state regulators that if it were granted a monopoly, it would spend money gained through efficiencies to improve the health of the people it serves.

“Maintaining the current state is not an option for us, particularly if we want to do things differently for our neighbors and friends,” Leonard said.

What difference looks like is slowly beginning to emerge.

Last fall, Ballad notified the Virginia Department of Health that it planned to make changes in Norton and Wise County. Since then, Ballad has met with state health officials and supplied more documents. Much of that information has been kept from the public under Ballad’s assertion that it needed to be protected as proprietary information.

Early on, Ballad informed the state that it would no longer perform surgeries at Mountain View, as one team could not safely cover two hospitals 12 miles apart. But Ballad did not make a public announcement, and state officials said they were legally barred from telling the public.

When the change was confirmed and reported in June, Ballad’s leaders said they would be more forthcoming in explaining changes in Wise County. In mid-August, Ballad released a four-page document explaining that it would close Mountain View’s emergency department, intensive care and inpatient units, and its reasons for doing so.

Ballad also said it was working toward adding much-needed behavioral health services, boosting cancer care and working with a visioning committee of medical, educational and community leaders to help determine how best to identify and provide needed services.

A ghost hospital

Mountain View’s four stories are nestled on a serene hillside above Norton. One floor is lively. It was recently renovated and has 44 beds for patients who require care between hospital and home, and for long-term patients for whom this is now their home. Ballad said that won’t change.

The day before, 22 patients had come for emergency care, a handful more than on most days. Otherwise, the building is idle. The lobby is empty, the elevator arrives with haste, the operating rooms are mothballed, and no visitors roam the dimly lit halls.

When Leonard and Kennedy took over management, they began to make changes. Medical and surgical patients were kept in rooms lining two long hallways as if the hospital still cared for dozens of patients, rather than for two or three.

Across a corridor, behind a closed door, ICU nurses cared for another two or three patients.

So they moved the medical and surgical patients into the ICU. It’s helped with staffing, Kennedy said, but there still aren’t enough nurses.

“Last weekend I got a call that said we only have two because one of our nurses called in sick. I sent a supervisor down there with them and said, ‘Don’t take any more patients,’ ” he said. “That’s what creates a diversion.”

The word “diversion” is heard often in Ballad’s world. It happens when patients are turned away from one hospital and sent to another. Critics blame Ballad’s management, but diversions and nursing shortages predate the merger. Ballad places a unit on diversion when it has more patients than staff to care for them.

In the past, if a Wise County hospital was on diversion, patients from both health systems would be sent to Tennessee. But now the former competitors look to each other first.

“In the old world, we were fairly quick to transfer and compete. With a common leadership, we continue to ask, could we have kept this patient? Would it have been safe to keep this patient? Do we have the specialties here?” Leonard said.

Since last fall, that has helped keep 700 patients from leaving the county.

Most transfers to Tennessee now are for a higher level of care, but diversions at one of those larger Ballad hospitals trickle outward, affecting the community hospitals.

A Norton emergency room supervisor reported during the morning huddle one diversion that affected a patient with anaphylactic shock.

“We were trying to go to Holston Valley [Medical Center in Kingsport, Tennessee], but they were on ICU diversion yesterday,” she said. Instead, the patient was flown to Bristol.

But while the patient was still in Norton, the lone physician was tied up with the case, which then increased the door-to-discharge time for other patients.