The benefits and challenges of running a rural health system

Dartmouth Health CEO Joanne M. Conroy, MD, shares her perspective on what it’s like to lead a rural academic health system and how rewarding she finds her position.

Editor’s note: This conversation is a transcript of an episode of the HealthLeaders podcast. Audio of the full interview is available here and lower.

Joanne M. Conroy, MD, has served as President and CEO of Dartmouth Health (formerly Dartmouth Hitchcock Health), New Hampshire’s only academic health system, since 2017. Her career has come full circle, as she earned her graduated from Dartmouth College in 1977.

The health system serves rural communities in New Hampshire and Vermont through six hospitals, a visiting nurse and palliative care program and numerous clinics, and operates in partnership with Ivy League University.

Additionally, Conroy is the president-elect of the American Hospital Association and will become president of the AHA in 2024.

During a recent HealthLeaders podcast interview, Conroy shared his thoughts on the benefits and challenges of leading a rural health system, outlined his 4 principles of leadership, and offered advice for future leaders.

This transcript has been edited for clarity and conciseness.

HealthLeaders: What is Dartmouth Health’s role in serving communities in New Hampshire and Vermont?

Joanne Conroy: When we think of the communities we serve, it’s not just the patients we serve, but the communities in which the patients live. We realize that in rural parts of the country, your postcode has a lot to do with your healthcare, and so when we think about serving communities, it’s not just about meeting the healthcare needs of patients. we serve, but to understand and try to mitigate the environmental and social factors that lead to poor health.

We have a wonderful population health group that has a broad definition of population health, and they’ve done a longevity analysis by zip code. [They found] you can live in Claremont, New Hampshire, and your expected life expectancy would be 15 years less than if you lived in Hanover, New Hampshire. There are many reasons why these are less healthy environments for people to live in and raise their families. These are the things we focus on; problems associated with simple things like adequate housing, access to fresh food, even how communities deal with opioid use disorders; all of this has an impact on communities and the health of the people who live there.

We are the most rural university medical center, so our reach is really wide. Not only do we serve patients right up to the Canadian border, but we also serve many patients in rural Vermont. We only have 170,000 people within a 30 mile radius. I think the second most rural academic medical center is the Mayo Clinic in Minnesota and they have about 230,000 people within a 30 mile radius, so that’s how your degree of rural nature is determined.

With this comes great opportunities to use telehealth, to provide services to our neighboring hospitals that are not part of our network in a way that allows them to be financially strong and sustainable so that they can continue to serve these communities. Essentially, when you serve rural communities, you serve through other members of those communities: other hospitals, other organizations, other not-for-profits. This is how you are effective in providing care in rural America.

HL: What are some of these challenges that your organization faces due to its status as a rural health system and how do you address them as CEO?

Conroy: Recruiting people to come and work in rural America has been difficult for years. Here are some things we did:

1. Understand the barriers that prevent people from moving to the rural areas we serve. Sometimes it’s about housing and being able to access and identify housing for a person or their family.

2. Transportation. We support a number of transit systems because they move our employees and they also move our patients.

3. Create a range of experiences for service providers [and] clinical staff so they can see the full continuum of how we provide patient care. Our Hospitals [provide care] at our university medical center where it can be super intense, especially as we’ve been through the pandemic. But they also provide inpatient services in our critical access hospitals. People can blow off some of the intensity of the academic medical center to care for people in a smaller hospital that can focus on surgical throughput or care for people with low-acuity issues in the community.

The same possibility is offered to our nurses. They can move up the career ladder by working in several different rural environments. They don’t have to leave the system to advance their careers because we are very widely distributed.

HL: Earlier this year, the health system was renamed Dartmouth Health. Why was there a rebrand and what was the three-year strategic plan behind the new name and logo?

Conroy: It shouldn’t have taken three years, but we were doing it in the middle of a pandemic. A lot of people would say, ‘Why didn’t you just quit?’ but we felt we had changed so much as a system over the past five to six years that we needed to reintroduce ourselves into the community.

Part of rebranding was spending time thinking about who we were in the community and comparing ourselves to other organizations in the North East. Our NCI-designated cancer center has the highest patient engagement scores of any NCI-designated cancer center in the country, our children’s hospital is the only one in the state, [and] we are the only academic medical center in the state. The innovations and the care that people can get here at the university medical center is truly amazing and they can access this care from anywhere [and] communities in which we have facilities.

In reflecting on who we were, we said we were world-class institutions that were woven into the fabric of our communities, and that is part of delivering rural health care. There is no anonymity. When I go to the local supermarket, you are going to have a conversation with people who receive care at your facility or who work at your facility. And sometimes, frankly, you solve big problems in aisle three of the co-op.

That’s the beauty of living in a rural environment when you’re so close to the people you serve, and we felt it was important to talk about us as part of the community. It’s different when you’re providing care to your friends and neighbors, rather than people you may never see again in a more urban environment.

HL: What has your career path been like so far?

Conroy: Well, I never thought I would end up here. I graduated in 1977 from Dartmouth College, one of the first coeducational classes here, and it was a great experience. I was a full-fledged scholarship student and worked at a local restaurant for three of the four years here, which allowed me to pay for everything the scholarship doesn’t cover that is part of your education.

I left here without thinking of coming back and moved to South Carolina. My subsequent travels, however, kept taking me further and further north. I was working outside of Boston when someone called me about work [at DH]. I applied, and interestingly, during the interview I realized that it was an opportunity for me to repay a debt I owed to this large community that had supported me in my education. I’m not sure I could have achieved what I’ve achieved in my life without a full scholarship, as well as an incredibly supportive community that became my friends and neighbors while I went to study here in Hannover.

Sometimes you feel like your career is going in circles and so it seemed like exactly the right decision.

HL: How would you describe your leadership style and how has it evolved over your career?

Conroy: As you go through your leadership experiences, you begin to depend on more than facts. You depend on your instincts and there is something about your intuition that cannot be ignored as a leader.

I give a lot of leadership talks, and I have four principles that I use all the time:

1. Authenticity. You must be an authentic leader. It means people feel like you’re not manipulating them, that you’re being honest and direct with them. Part of that is being a little vulnerable, which is always great when a leader can do that with great authenticity.

2. Integrity. We all have to commit to things. And if we can’t keep them, we need to tell people why and when they can expect us to keep those promises.

3. Liability. We all make choices, and you must be responsible for the choices you make; they take you to where you are.

3. Commit to something bigger than yourself. That’s what health care is for. People who come here for financial or reputational gain are probably here for the wrong reasons. There’s nothing that supports leaders in healthcare more than looking at the impact you have on the lives of everyone you work with and care for.

HL: What advice do you have for aspiring health leaders who are curious, but perhaps wary, to serve in leadership roles for rural institutions?

Conroy: I would tell them that this is an important part of their leadership training to understand rural health care. 20% of people in the United States receive health care in rural health systems, so it’s not like we’re an anomaly.

In rural systems, you know everyone and it’s a great way to learn how to get things done. And it’s not always because you found the answer to a problem, but it’s because you develop relationships. You can appreciate the challenges faced by the people you work with because they are your neighbors. You learn a lot about how to create win-win solutions, how to lead authentically and [how to] build coalitions in your community to improve health. All of these skills are extremely important and transferable to a higher density environment.

Sometimes it’s hard to get those experiences in a busy urban or suburban environment where you don’t necessarily know everyone. I can tell you that the first two weeks I was here, I got a call from the state governor to welcome me and introduce himself. This doesn’t happen in many large sites. And there are a lot of benefits to really spending part of your career in rural health care.