Many experts and lay people alike believe that this nation is facing a health care crisis of major proportions. Costs are rising, reimbursement programs are declining, the population is aging and living longer than previous generations, and more hospitals are operating in the red than at any time in history. All of these problems are even more acute for small, rural hospitals all over the country. Fortunately, however, hopeful signs of creative solutions are emerging, often on a small scale, including the inspiring story of two hospitals in two towns in western North Carolina – Sylva and Bryson City – located about an hour west of Asheville. According to Mark Leonard, CEO of West Care Health System of Sylva, “No one in Washington is developing national health policies that address these critical issues. The last I heard, just in North Carolina alone, 30 to 35 percent of the hospitals are operating in the red. We’d better figure out how to deploy our health care resources so that folks can be treated at an appropriate level in their own hometown. The more pressing issue may be, how do we keep folks afloat until long-term solutions take hold?” The answer in Sylva and Bryson City was old-fashioned neighborliness – one institution reaching out to help another in distress – and the result of their cooperative venture is a grass roots alternative that could be replicated elsewhere. Indeed, their success story has been presented to many regional and national conferences as an example of what can work and how to make it happen. Looking back, Leonard is surprised he is living and working in such a small place. He was working in a hospital in Dalton, Georgia, in 1989 when an executive search consultant called about a position in Sylva. “I said, ‘Tell me about the job and the community,’” Leonard recalls. “He did and I said, ‘It sounds like the kiss of death.’ All of the hospitals that are closing down are in small, rural communities, fewer than a hundred beds. I had worked in a 300-bed hospital and a 700-bed hospital.” Fortunately, the consultant persisted, so Leonard went to Sylva just to go through the interview experience, with no intentions of being a serious candidate. He got halfway through the weekend and called his wife to tell her to schedule a time to come check the place out. In 1990, Leonard took the position of vice president for professional services at C.J. Harris Community Hospital in Sylva. In 1997, he oversaw a merger with Swain County Hospital in neighboring Bryson City. He is now administrator of the renamed Harris Regional Hospital and CEO of the newly formed WestCare Health Systems in 1998, which oversees both facilities. Their primary market covers four rural counties: Jackson, Macon, Swain and Graham. They also serve patients from Clay and Cherokee Counties and areas of northeast Georgia. “What really intrigued me were the people,” Leonard says. “There was a connection between the community and the professional staff and the management team that I had not experienced in other job settings, certainly not in other hospital settings. I believe that is the secret of our success, the connection we have, the teamwork, the attitude.” That is also the secret of the successful merger of the two hospitals, a tricky process of change management that took nearly two years to complete. The Duke Endowment made a grant of $77,000 in 1997 to fund some of the strategic planning, and to support a study of the financial viability of merging with Harris Regional Hospital and converting the Swain County Hospital to Critical Access status – the first such hospital conversion in North Carolina. Ronnie Sloan is the current administrator of Swain County Hospital. He too came to the area from a larger place, a reluctant candidate who quickly became an enthusiastic member of a small community. He began as director of cardiopulmonary services for Harris in 1991, stepped sideways to become radiology manager, worked through the transition period of the merger, then up to the top position at Swain in 2003. He was one of the first managers to take on the administration of two departments in two facilities, and he saw all the difficulties at ground level. “Bryson City is a football town with a lot of pride,” says Sloan. “The community saw this initially as a hostile takeover… they’re going to take away our staff; they’re going to make us a band-aid station. What they didn’t know was the truth of our financial situation. Swain was losing $2 million a year. The community had no idea. But you could see the loss of confidence in the market share data. Before this merger, people in this community would drive past the Swain County border, going to Jackson County or to Asheville for medical service.” What about the other side of the county line? “While the majority of folks at Harris were supportive of the merger,” says Leonard, “I’d be remiss if I didn’t tell you there was a vocal minority that thought we were sinking money into a dark hole and that we should have taken those dollars and kept them in Sylva, invest in Harris, build it up and let Swain close down, shut the lights off.” But thanks to the dedication and hard work of people in both communities they pulled it off. The participants chose a powerful and appropriate symbol to seal the deal. “By far the coolest part of the merger was signing the agreement,” recalls Sloan. “We did it on the Smoky Mountain Train, which runs between Jackson County and Swain County. We signed it coming across the county line.” With the merger complete and finances stabilizing, WestCare set about to have Swain designated as a Critical Access Hospital, to consolidate all of the health care services of Swain county in one place, and to renovate the facilities to bring it up to the level needed to fulfill its new mission. The Duke Endowment granted $350,000 in 2001 to support the renovation and an additional $350,000 in 2002, for a total contribution of $777,000. Among other things, the renovation built a new addition, a waiting room and central communication center that serves all needs, and helped make Swain ready for its new Critical Access role. “Now all the health care in the county happens right here,” says Sloan, “from ER to pediatric services to primary care physicians to county health services…. We have common registrations, computer systems and waiting areas. This went from a waiting room that had 15 to 20 people a day to literally 250 to 300 people a day. Now if you need health care in Bryson City, people say, ‘Just go to the hill.’ We’re known as Hospital Hill. And this marvelous waiting room is a giant portal to all the services we offer.” The merger also allowed both hospitals to share technical equipment and diagnostic services. Harris bought a new state-of-the-art CAT scanner and donated its previous model to Swain – a huge step up for both places. The scanner in Swain is also connected to Harris by computer, so they no longer have to send film by courier. That speeds up time, which can often be critical. Still it takes huge files up to 45 minutes to transmit, so WestCare undertook its latest capital improvement – a $5 million project to redo its IT system, including putting in fiber optic to connect the two facilities. The Duke Endowment again helped with a new grant of $300,000. The positive results can be seen in the numbers, which have been going up steadily – things like ER visits, registrations, radiology and CAT scan procedures, and a bottom line now in the black – Swain now contributes almost $1 million annually to its reserve fund. Best of all, perhaps, community confidence in Swain County Hospital is at an all-time high. How did it all happen, against the odds? “The best analogy I can think of is this is the result of one neighbor reaching out to another,” says Leonard. “Given limited dollars and overwhelming demand on our industry, we must find a way to work collaboratively. I believe this is a model that worked; it is a model that can work for other communities as well.” It Takes A CommunityThe successful merger of Swain and Harris hospitals has resulted in an upsurge of confidence in Bryson City. Consider this: two years ago Swain had a handful of volunteers, maybe five or six at most. Now it has 25. In April 2004, a group came to the administration and said they wanted to start a thrift shop. The administration said yes, and put them in the old physicians’ building behind the hospital. The Thrift Shop used its proceeds to put a canopy at the new hospital entrance to protect patients and visitors from the weather. A little more than a year after the shop opened its doors, it had raised $38,000, enough to pay the entire expense of the canopy and its installation. Some of the volunteers have been involved with the hospital since it first opened in the 1950s. “My mother and I helped put up the first curtains in here,” recalls Maxine Wright. “We sewed them here on the premises. I worked for years in physical therapy, now I serve as a volunteer, behind the desk, wherever I am needed.” Bernard Jensen first came to Swain as an anesthetist. “I drove into town on July 3, 1967, and Dr. Mitchell had three cases lined up. I had worked in Chattanooga for 10 years but had never dreamed of coming to a small town. Dr. Mitchell did a little of everything, anything below the eyes and above the toes. I worked here until 1998. The day they had my retirement party I signed up for the auxiliary and I’ve been a volunteer for the last eight years.” Jensen knows first-hand how difficult the merger was. “We were in a position of facing death. We had to borrow money to pay the salaries and the bills at the end of the month. We borrowed $160,000 to pay the bills the last month we were alone. We had some pros and cons in the community, whether to join with Harris. Our pride might have been hurt a little, but it was either close or swallow our pride and cooperate in this merger.” He also knows how perceptions have changed since then. “I know a lot of people here, probably several thousand people in this town…. They see the progress that has been made; they appreciate having all these services right here in one place. I’m proud of the people way back, and I’m proud of what’s being done now.” | 
