Rebuilding Paradise: Finding health care after total destruction

02 June 2019

USA – PARADISE, Calif. — This Northern California town, decimated by wildfires, is trying to rebuild a health care system in a place that no longer exists for a future that’s impossible to predict.

Paradise is little more than a large charred debris removal site — and it lost its hospital, several clinics, its nursing homes, its doctors in the fire last year. Without health care, Paradise, a remote town 90 miles from Sacramento nestled into the foothills of the Sierra Nevada, has no chance of coming back.

Recovery may also provide opportunity. Paradise is trying to piece together a new, more flexible health care system, relying on new partnerships and better technology, including telemedicine. If it works, Paradise could become a template for how to deliver health care to rural America, not just those communities hit by disaster, but areas that have seen hospitals close and the numbers of doctors dwindle.

“They have the really unique perspective right now to create something based on need that can grow in the community as it looks toward the future,” said Brock Slabach, senior vice president with the National Rural Health Association.

A $19 billion federal disaster assistance bill, long delayed in Congress because of disputes between President Trump and the Democrats, may finally be approved in the coming week. California stands to get up to $12.6 billion, and some of that money will come here to Paradise, where the Camp Fire, the biggest and most destructive fire in state history, killed 85 people and destroyed 14,000 homes when it struck six months ago.

The new vision for health care here builds on primary care based in the community, with telemedicine access to specialists. Whether the town will have a hospital of its own — or just an emergency facility, at least for the next few years — is an unresolved question.

Adventist Health hasn’t decided whether to rebuild or reopen Paradise’s only hospital, which was severely damaged though it didn’t burn to the ground. Physicians have left because they have no place to practice or live. Patients have fled to makeshift homes with friends or relatives, uncertain whether to return.

The rebuilding task for the city is monumental, and health care has to be at its heart.

“I don’t think there is a similar instance in the United States where a community has been essentially completely destroyed and had to rebuild,” said Richard Thorp, a physician and president of the Paradise Medical Group, which served about 10,000 patients at three clinics in what was once a serene rural community.

Paradise has one of the worst cleanup jobs since 9/11, but signs of recovery are starting to appear. Thorp’s medical group has started seeing patients at its one surviving clinic. On the other side of town, Adventist’s Feather River Health Center, a federally designated rural health clinic that treats Medicaid patients, reopened in late December.

“Every time there’s a ribbon-cutting around here, there’s a little more confidence,” said U.S. Rep. Doug LaMalfa who was on hand for the clinic’s official re-opening last week. He was the only California Republican to defy Trump and vote for the Democrats’ aid package.

While the federal money stalled, state officials tried to step in. The California Legislature is considering a bill designed to help Paradise reclaim some of its emergency medical services. For instance, while Adventist Feather River, the 101-bed hospital, sustained too much damage to stay open, its ER survived. California law doesn’t allow freestanding emergency departments, so a bill would let Adventist Health operate the ER for up to six years under a consolidated license with another Adventist hospital 50 miles away.

“They’ve just got to have something somewhere,” said the bill’s author, Republican state Sen. Jim Nielsen, whose district includes parts of the fire area. “Our biggest challenge since the fire has been to inspire confidence in the citizens to rebuild and come back.”

Adventist Health supports the bill but hasn’t made any decisions yet on its future footprint. “We are anxious to provide access as much as we possibly can in a quick time frame, but it’s hard to do that,” said Jill Kinney, the hospital’s spokesperson.

Building a hospital is a complex, multiyear process under the best of circumstances, Kinney said. “Right now, some of our challenges are we don’t know where the population is going to end up,” she said. “Are they going to rebuild? Are they coming back? It’s really hard to tell what the community will look like.”

Rigid federal regulations has made it hard for rural communities to rebuild health facilities after disasters, says Slabach. Senate Finance Chairman Chuck Grassley (R-Iowa) offered a bill that would allow Medicare to reimburse a new kind of rural clinic-hospital hybrid. But it hasn’t gotten traction in Congress.

Paradise’s Feather River hospital didn’t qualify as a “critical access” hospital — a designation that offers rural hospitals higher Medicare rates — and won’t qualify as one without a legislative fix or waiver, because of its size and proximity to hospitals in Chico and Oroville, respectively 16 and 21 miles away.

And changes in medicine — a new emphasis on primary and community based care, less on acute care hospital settings — means Paradise is rethinking its needs. Slabach, of the rural health association, said post-disaster communities need flexible options. Many of them “really don’t want or need inpatient capacity because the population no longer supports it,” he said.

But while some people could get to Chico or Oroville with relative ease, it’s harder for elderly residents who lived in Paradise. The topography — on a wide ridge surrounded by deep canyons — makes it even more remote.

In the immediate aftermath of the fire, doctors worked out of Chico’s Enloe Medical Center and clinics. With the reopening of the Paradise Medical Group clinic, the practice also unveiled “PMG Connect,” a virtual care platform supported by Teladoc. Blue Shield of California gave the medical group $2 million to help pay for the technology, while covering 90 days of payroll and other expenses.

The technology allows patients to connect virtually with their doctors online and through mobile apps. The group is starting to experiment with home-based care and remote patient monitoring. The hospital’s closure has limited Paradise’s health capacity to primary care, increasing the need to access outside specialists.

If the hospital rebuilds, it will undoubtedly do so with a smaller footprint, one that reflects the overall trend of shifting care to outpatient settings.

Dustin Corcoran, CEO of the California Medical Association, said Paradise’s rebuild from the ground up offers it the opportunity to be the “most technologically advanced, the most forward-facing medical group in the entire state of California.”

The medical group already had a strong technological foothold; a new cloud-based EHR system retained the last three years of patient records, and the group’s quick-thinking technology manager managed to save the hard drives containing earlier patient history from a basement before the clinic burned to the ground.

Problems like recruiting physicians and providing specialty care services “were always an issue pre-fire,” Corcoran said. “Now it’s a greater issue. But now they have the technological capacity and that’s quite an asset to the community as it rebuilds.”

“As we restore Paradise, the medical group and its services, it probably won’t be the same as it was before,” said Bradford Ogden, 65 and a longtime resident and patient. “It will be different. It might be better.”

2. June 2019/by GFMCadmin