While most rural hospitals struggle, Titus County facility advances care for patients (2024)

MOUNT PLEASANT — Brenda Godoy is excited to be back in the hospital.

As a Mount Pleasant High School student, Godoy spent time learning about careers at Titus Regional Medical Center, and she later became one of the facility’s community health workers, analyzing social problems that keep some people from having access to healthcare.

Now a third-year medical student at the University of North Texas Health Science Center, she’s one of seven aspiring physicians participating in clinical rotations at the hospital, where students work as the protégés of doctors .

“This is my hometown. I know the people here,” Godoy said. “I just like that I’ll be able to contribute to that and, hopefully, Mount Pleasant in the future.”

A special arrangement with Titus Regional allowed Godoy to come back home to learn. And the ability to make those kinds of arrangements is what sets this hospital apart from others, its leaders say.

The hospital has garnered numerous commendations for its advanced cardiovascular, maternal and stroke care units, and by next year, it’ll offer new physicians a place to complete the last phase of their education — and start the first phases of their careers in rural medicine.

Titus Regional leaders have begun community outreach initiatives to learn more about groups of people who don’t have equal access to healthcare, and they’re figuring out ways to better serve them.

At a time when rural hospitals across the nation are in crisis, this Northeast Texas facility continues to innovate based on the philosophy that patients in rural areas should have the same level of healthcare as people elsewhere.

“We’re trying to do things here that will allow us to not only survive, but to thrive,” said CEO Terry Scoggin.

‘Not the healthiest people’

At the interchange of Interstate 30 and the U.S. 271 Business Loop, the tan-colored Titus Regional Medical Center tower stands out from the amalgamation of gas stations and hotels nearby. And it stands out from other hospitals in the region, too.

Titus Regional is the last independently owned rural hospital in Northeast Texas. Most in the area have been purchased by the Christus Health System or the University of Texas Health network, part of a trend in which larger health systems purchase financially struggling rural hospitals.

Though rural hospitals may be the only place patients in remote areas can access lifesaving care, those facilities are on life support. In East Texas, hospitals in Gilmer, Grand Saline, Commerce, Clarksville, Mount Vernon and Linden have closed, joining the ranks of more than 100 rural hospitals across the nation that have shuttered since 2005, according to research from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

Almost 100 more have been converted into other kinds of facilities.

Rural hospitals aren’t paid for their services as highly as their urban counterparts, partly because they’re not part of large health systems that have more leverage to negotiate better payment rates with insurance companies, Scoggin said. They also tend to serve populations that are largely uninsured. Roughly 37 percent of Titus County residents lack health insurance, he said.

“You’re expected to do the same business at the same level, but you’re getting paid a significant amount less,” Scoggin said.

Those same hospitals face staffing shortages, partly because of perceptions that medical providers will have better pay and quality of life in urban areas than rural ones. However, that perception might not always be accurate, as some rural physicians could earn more than urban ones based on several factors, the New England Journal of Medicine reported in 2019.

Northeast Texas has fewer primary care providers per capita than the rest of the state, yet it has the state’s highest rates of death from heart disease, certain cancers, kidney disease and diabetes, according to data compiled in 2021 by researchers at the University of Texas at Tyler.

“We’re not the healthiest people in Northeast Texas,” Scoggin said.

Staffing shortages, mounting debt and increasingly old and unhealthy populations leave hospitals in rural areas with lots of sick people to care for — but without the resources they need to do so.

“All rural hospitals throughout the United States are struggling, Scoggin said.

But in Titus County, the prognosis for rural healthcare might not seem as bleak.

Innovations in care

When Kathy Griffis, the hospital’s chief nursing officer, got Scoggin “fired up” about improving stroke care in 2013, the hospital was able to quickly implement a new program designed to reduce deaths from strokes.

For eight years, the hospital has been recognized by the American Heart Association as a Gold Plus hospital for stroke care, and in 2023, it was named a Target Stroke Honor Roll Elite award recipient — placing it in the top 16 percent of all U.S. hospitals for stroke care, Griffis said.

So, how was Titus Regional able to build a revolutionary stroke program in rapid time?

The 174-bed hospital is owned by Titus County taxpayers, whose property taxes partially fund it. Its 850 employees serve a population of about 100,000 spanning several counties in the region, Scoggin said.

An elected board of directors is the hospital’s ultimate governing authority — not Wall Street investors or corporate executives on the East Coast, Scoggin said. The people making decisions about the hospital’s operations, and the health-related needs of the community, live and work there.

“We’re small, and as a rural hospital, we’re nimble, so we can do things quicker than a large health system,” Scoggin said.

Once hospital staff saw the success of the stroke program, the “fire” that Griffis started spread to other areas of the hospital, Scoggin said. The next focus: cardiology.

From 2015 to 2017, Titus County was one of several in Northeast Texas with the highest rates of death from cardiovascular disease: 559.7 per 100,000 people, according to the Centers for Disease Control and Prevention data.

Cardiovascular mortality is highest in rural areas that often lack the cardiologists needed to treat their populations, and nearly half of all U.S. counties don’t have a cardiologist, according to Becker’s Hospital Review.

But in 2016, the hospital opened its first cardiac catheterization unit, allowing doctors to treat patients who’ve had heart attacks. It was the kind of place Dr. Stephen Sigal, a cardiologist who practiced in Tyler for several years and helped establish the unit, wanted to be. He grew up in a rural area that was similarly underserved, and he wanted to help fill the gap in care.

Cardiologists have taught the hospital’s ambulance crews to diagnose heart attacks, Griffis said. Once ambulance crews report that they’re en route to the hospital, the hospital’s cardiac crew is called in quickly, and patients are taken immediately to the cardiac unit. Within 16 minutes of arriving at the hospital, patients are in the cardiac unit for a balloon angioplasty, which opens blocked blood vessels.

“It’s really good stuff. It makes you want to come to work every day,” Griffis said.

The unit has had a substantial effect on the county’s health, Sigal and Griffis said: The rate of cardiac deaths in Titus County dropped to 550.7 per 100,000 people by 2021, according to CDC data.

Sigal called that a “big improvement for us in a short period of time.” The hospital was one of the first in the nation to be designated a Primary Heart Attack Center by the Joint Commission, a nonprofit organization that measures the quality of roughly 22,000 U.S. hospitals. Since then, the American Heart Association also has bestowed some of its top honors on the facility.

“It takes a real commitment to quality of care and to wanting to be involved, not just to get a certificate on the wall, but to improve your processes so that you really are delivering the best care possible to the community,” Sigal said.

At the same time, the hospital opened its cardiac unit, the hospital’s labor and delivery unit began increasing its preparation for emergencies and coordinating with other hospital divisions to improve overall patient care. That effort paid off in 2022, when Money.com and the Leapfrog Group, a hospital safety rating organization, named Titus one of the best hospitals in the U.S. for maternity care.

Patients have noticed how the hospital’s services have improved, Scoggin said. In the past five years, he’s gotten more compliments from patients in the community than he used to.

So have physicians. At first, convincing community members that they could get the same level of care at home that they could in a metropolitan area was challenging, Sigal said. But in time, trust has been built.

“It’s very worthwhile because you see these patients in Walmart, and they say, ‘Wow. I’m so grateful that you guys took care of us, and we’re here to talk about it.’ And it’s hard to replace that,” Sigal said.

‘You want to come to work’

The United States is facing a nationwide nursing shortage, and it’s compounded in rural areas, according to the American Hospital Association. Medical workers may tend to gravitate toward urban areas that offer higher pay and better educational opportunities for their families, according to a 2020 story in the American Association of Medical Colleges.

But Titus Regional has maintained a low attrition rate, and it doesn’t have to hire temporary traveling nurses to cover shifts, Griffis said. She attributes that to the hospital’s culture — and its staff’s connection to the community.

About half of the hospital’s workforce lives in the area, Scoggin said. They’re invested in the community and their fellow Titus County residents.

The hospital allows nurses to transfer from one department to another, giving them the chance to learn new things and keep from getting “bored” — the main reason people leave jobs, Griffis said.

It’s a friendly place to work, too, she said.

“We want it to be a place that you come, and you want to come to work,” Griffis said. “You’re going to see your best friend, and you’re going to work beside that best friend, and you’re going to provide this beautiful care to this patient.”

While some medical providers might eye the excitement and vibrancy of urban living, others are looking for the kind of small-town, slower-paced lifestyle a place like Mount Pleasant offers.

That’s part of what appealed to Nicki Magee, the hospital’s director of adult inpatient services, when she moved there in 2013. Mount Pleasant is a good community to live in and raise a family, and the hospital is a place where everyone “is passionate about our community, and we want to do what’s best for them,” Magee said.

While the hospital might not offer some specialized types of care that urban hospitals do, “our little bitty hospital does huge things,” she said.

“That’s what it’s like being part of Titus. It’s being on the cutting edge and the front line in taking care of our community.”

Teaching the next generation

After completing medical school, new physicians must complete a residency working at a medical facility. And starting in August 2025, they’ll be able to do so at Titus Regional.

The hospital is starting its first medical residency program in partnership with the Arkansas College of Osteopathic Medicine, and it’ll emphasize rural medicine. The hospital will offer internal medicine residencies during the first year, add OB/GYN residencies during the second year and bring in family medicine during the third year. The hospital expects to have more than 60 physicians completing residencies there once the program is fully rolled out, Scoggin said.

The program is one way the hospital will train up the next generation of providers to keep Titus County healthy, Scoggin said. By offering a residency program, the hospital can entice Mount Pleasant youth who are interested in the medical profession to return there after completing medical school — and, hopefully, stay.

Rural residency programs such as Titus’ are one way to bring future providers to small towns, according to a 2015 review published in the National Library of Medicine. The Health Resources & Services Administration has offered grant funding since 2019 to help establish the programs, and more than 300 resident physicians have been enrolled in them, according to the agency.

“We’ve got to figure out ways to create our own workforce,” Scoggin said. “And if we don’t continue to do that, we’re going to miss out. We’ll be in trouble.”

The hospital already is hosting rotations for third-year medical students, including Godoy, giving them a chance to work alongside and learn from doctors who have various specialties. So far, the hospital has partnered with the Arkansas College of Osteopathic Medicine and Sam Houston Medical School in Conroe to bring in students for rotations.

Godoy, a student at the University of North Texas, is the exception.

“Brenda’s from here, and we’d like to help Brenda out,” Scoggin said. “It just makes it easier for her so she can stay at home when she goes to medical school.”

‘Break down these barriers’

On a recent Wednesday, Godoy donned blue scrubs and a stethoscope as she talked about her life in Mount Pleasant. The day before, she became an aunt; her sister delivered her baby at Titus Regional, and Godoy was in the room. She got a “preview” of what her OB/GYN rotation will be, she said.

“I’m just really here to learn as much as I can from everyone in the field,” she said. “Everyone I come across, even the nurses, they’ve been a lot of help so far.”

She likes the small-town atmosphere that Titus County, and Titus Regional, have. She’s also eager to help the community’s Hispanic population, which makes up nearly half of the area’s population.

Godoy is Hispanic and knows that language barriers sometimes keep people from seeking medical care. Titus Regional’s Community Care Center, however, is a bilingual clinic, meaning all employees speak English and Spanish. That cuts out the need for translators between the patient and the provider, Godoy said.

“They’re really grateful that they can come and just talk to the doctor and just have that personal interaction with a doctor,” Godoy said. “Being able to break down these barriers in medicine is something that I’m striving for.”

That Titus Regional already is working on that goal is part of what makes her want to work there — both now as a medical student and in the future as a physician.

“If I can do anything to help spread the word about what Titus is doing and the changes they are making to better serve our population, I’m here for it,” she said.