The average cost of storm repairs is about $10,000 for “moderate” wind-based damage, and a minimum of $4,000 to handle water damage. That’s less than a quarter of a new home price. Add in price-gouged flood insurance costs and consider a scenario of heavy damage, rebuilding is still a fraction of buying anew.
Read more via Scalawag: Weathering Storms.
Bridging Access:
Across rural America, communities of color may be facing barriers to health care, but they’re also laying the groundwork for a more equitable future. Whether it’s hospitals reopening, a community’s holistic approach to maternal care, or the grassroots work to bring comprehensive services to immigrants, these stories offer a road map. This story is part of a collaborative reporting effort led by the Institute for Nonprofit News’ Rural News Network, with visual support from CatchLight. Photo credits: Ariel Cobbert and Aallyah Wright.
BROWNSVILLE, Tenn. — On a late evening in 1986, sharp pains hit Alma Jean Thomas-Carney’s stomach like lightning.
Days earlier, she’d just returned home to Brownsville, after dancing all weekend at her high school reunion hundreds of miles away in Illinois. Maybe that’s where the pain originated, she thought.
She cried profusely to her husband to take her to a hospital. But not the local Haywood Park Community Hospital, a 62-bed facility built in 1974.
“Please don’t take me up there. Don’t take me up there,” she pleaded. He rushed her to the car and drove to Jackson, Tennessee, nearly 40 miles away.
When she arrived at the hospital in Jackson, she underwent exploratory surgery. They found cysts on her ovaries, a diagnosis she says she wouldn’t have gotten at Haywood Park.
“I didn’t trust I would get the proper care or care that would help me to survive,” she told Capital B.
Years prior, she experienced an unwelcoming environment from white staffers, including doctors, at Haywood Park. Upon entry, she’d walk to the reception desk, only to be ignored or met with unpleasant looks.
“They acted like you were invisible,” she said. “Whether they were talking or drinking coffee, they kept doing whatever they were doing and didn’t pay attention to you.”
Haywood Park’s reputation deteriorated over the years. Some residents voluntarily drove elsewhere if they could, or went without critical care, which contributed to low patient volume. Many more reasons, such as financial instability, resulted in its ultimate demise.
The hospital closed in 2014, after a long, slow decline. But, the news saddened the community, including Thomas-Carney. “Despite my ill-feelings or experiences I had in that environment … you have indigent people living in Haywood County who need to get to the closest facility available.”
From 1990 to 2020, 334 rural hospitals have closed across 47 states, which disproportionately affect areas with higher populations of Black and Hispanic people. Since 2011, hospital closures have outnumbered new hospital openings. In Brownsville, they’ve been able to do the impossible: reopen a full-service hospital. They’re not the only ones.
Less than three hours away in the heart of the Mississippi Delta, leaders in Marks reopened their facility in 2021, after a five-year shutdown. In neighboring Georgia, county officials received millions in congressional funding to reopen their hospital in Cuthbert, which closed in 2020. Currently, they’re researching what model is feasible for their town.
When a rural hospital closes, there’s usually no turning back. Yet, Brownsville became an outlier two years ago and is part of a growing but short list of hospitals in rural counties that have been able to fully reopen. What’s happening in this 68% Black town of 9,700 people is quite uncommon, health experts say. Usually hospitals cut back or reduce services, such as obstetric departments, to keep their doors open. The most recent alternative to prevent closures include the Rural Emergency Hospital designation, a new model established in 2020 that eliminates in-patient beds but keeps an emergency department in order to receive a boost in federal support. At least 29 rural hospitals have converted to rural emergency hospitals, according to Becker’s Hospital Review.
While this is a fix for some, it may not be the most viable for others, experts say.
“Once you’ve seen one rural community, you’ve seen one rural community; they’re very different. We understand that not every rural hospital that is struggling will benefit or will want to convert to this rural emergency hospital,” said Shannon Wu, senior associate director of payment policy at the American Hospital Association. “We see this as a tool in a toolbox for those that fit their community needs.”
Thomas-Carney lost faith in the local health system long before the establishment of Haywood Park 50 years ago.
As a kid, she witnessed her grandmother lying in a hospital bed in the basement of the Haywood County Memorial Hospital, a 30-bed facility built in 1930 during Jim Crow. Steel pipes followed the linings of the walls. The sounds of steam echoed in her ears.
“I just remember looking around, and it didn’t look like nothin’ that I had seen in a book about a hospital,” she explained.
Thomas-Carney’s grandmother’s experience was not uncommon, as most Southern, white-run hospitals refused to accept Black patients. The few that did placed them “on inferior Black wards, often in the basement, and usually with no separation by disease process,” writes historian Karen Kruse Thomas.
Kruse Thomas details how prior to World War II, hospitals in the South were racially separate and Black patients mostly went to all-Black hospitals, if they had one. Few and far between, Black hospitals were unaccredited, underequipped, and struggling to remain open.
In the 1940s, the federal government began to address hospital segregation through the Hospital Survey and Construction Act, known as the Hill-Burton Act. At the time, the South had the highest population of Black folks with the worst rates of morbidity and mortality. In 1938, the surgeon general called the South “the number one health problem in the nation.”
Today, the health disparities can be described the same.
Black people still experience higher rates of disease, chronic illnesses, and mortality in comparison to their urban counterparts. In Tennessee, Haywood County has higher percentages of adult diabetes, obesity, and overall poor health in comparison to the state and national averages.
Unfortunately, where you live dictates your health and the type of access you have.
Only recently did a study in the National Library of Medicine distinctly spell out that structural racism — in addition to poverty, education, and environmental conditions — is a major contributor to why such health disparities continue to persist.
“In rural areas, especially in the South, it is important to understand how institutional policies, such as the Jim Crow laws that segregated hospitals and neighborhoods, led to differences in resource allocation between white populations and nonwhite populations, which may impact healthcare access today,” the study’s authors noted.
Greta Sanders, a Brownsville resident, recalled how Eva Rawls, a Black registered nurse who worked at Haywood County hospital, was forced to work under the supervision of white women who were licensed practical nurses, even though she was the superior.
That hospital closed in 1974, the same year Haywood Park opened.
“When [the new owners] found out that a registered nurse was working underneath the LPNs, they were just blown away,” said Sanders, a retired lab technician who worked at Haywood Park. “When the white LPNs had to start working under her supervision … they did not like it.”
Many residents in Brownsville — the birthplace of the Queen of Rock ‘n’ Roll, Tina Turner — have received life-saving care at the local hospital.
One of those people: the wife of John Ashworth, a local civil rights activist and historian who co-runs the Dunbar Carver Museum with Thomas-Carney. Some time ago, Ashworth’s wife got stung by a bee. By the time she arrived at Haywood Park, her blood pressure was extremely high. They immediately admitted her and stabilized her.
“I have mixed emotions, but I really think it was a good hospital,” Ashworth said. “I am absolutely convinced that my wife would not be alive today if that hospital had not been there at the time.”
Ashworth believes some deaths could have been prevented had the hospital been open.
Fed up with the poor health outcomes in his community, William “Bill” Rawls Jr. ran for office. He became the first Black mayor in Brownsville in 2014. Before he could celebrate the win, the hospital closed its doors for good.
So, he thought.
Rawls set out on a mission to work with Michael Banks, a local attorney, and county officials to bring back the hospital. Like many small towns, the train tracks here still represent a divide, a symbol of racial segregation.
While Banks worked to find quality suitors for the hospital, Rawls started the Healthy Moves Initiative, a health education and preventive care effort. He hosted health fairs, quarterly free wellness screenings, built walking trails and a dog park, and created a farmer’s market. But, it didn’t create the impact he’d hoped for.
It’s still a work in progress, he says, but the challenge is getting more participation.
Two years after Brownsville lost its hospital, Marks, a small town in the Mississippi Delta, did, too. The closure of the only critical access hospital in Quitman County resulted in the loss of 100 jobs. Similar to Brownsville, limited health care access resulted in longer waits to receive emergency and medical assistance.
Six months later, the Black town of 1,600 people lost its only grocery store.
During this time, Velma Benson-Wilson returned to her hometown after 20 years in Jackson, Tennessee. It started as frequent trips to conduct research to write What’s In The Water?, a tribute to her mother. She stayed a bit longer to work as a consultant on cultural tourism for the county, particularly the construction of the Amtrak project and memorializing the history of the Mule Train, which kicked off the late Martin Luther King Jr.’s Poor People’s Campaign.
But, the health crisis and food desert in Marks motivated her to dig deeper.
Wilson became the Quitman county administrator, the first Black person and female to serve in the position. After she helped close the Amtrak deal in 2018, she turned her focus to the hospital and worked with the county supervisors to find a solution.
After working to save a hospital in Holly Springs, roughly 90 minutes from Marks, Quinten Whitwell, an attorney from Oxford, and Dr. Kenneth Williams, a Black physician, launched Progressive Health Group to keep rural hospitals from closure across the South.
Five years after the Marks hospital closed in 2016, its Certificate of Need was set to expire. The legal document was required to reopen, establish or construct a health facility.
Whitwell, in quarantine, worked with his team on a plan to get it approved by the state.
Manuel Killebrew, president of the Quitman County Board of Supervisors, said that state Democratic Sen. Robert Jackson passed legislation to help reopen the hospital. Soon after, in 2021, the county supervisors voted to reopen the hospital in partnership with nearby Panola Medical Center in Batesville, Mississippi. The county gave Whitwell’s group a loan, and Citizen Banks of Marks gave a $1 million donation to reopen the facility as Progressive Health of Marks, a critical access hospital. The same year, a local entrepreneur opened a new grocery store across the street from the hospital.
The hospital has a walk-in clinic, emergency room, radiology department, and several other services, such as telehealth, according to Mejilda Spearman, the administrator for the Quitman hospital. They currently have four in-patient beds and are currently renovating their senior care unit. They’ve hired fewer than 50 people. While they’ve seen a steady increase in patients since, they still struggle to get community support.
But, some residents still aren’t satisfied, Killebrew added.
“There’s still people who gripe, but the hospital here is the closest place to get medical treatment,” he said. “If one of their loved ones were shot or had a heart attack, they get here, and at least they’ll survive.”
Despite low support in Marks and Brownsville for a hospital, residents in Cuthbert, Georgia, have prayed for more health care options in their predominantly Black community of fewer than 3,100 people.
The Southwest Georgia Regional Hospital in Cuthbert, the county’s only hospital, closed at the height of the COVID-19 pandemic due to increased costs from aging infrastructure and underinsured and uninsured patients. Officials added that the inaction of Medicaid expansion in Georgia also contributed to the closure in Randolph County, which is majority Black.
Before the hospital closed, some uninsured residents relied on the emergency room for primary care. Now for emergencies or other care, many travel 30 minutes to Eufaula, Alabama, or nearly an hour to Albany, Georgia, said Cuthbert Mayor Bobby Jenkins.
Minnie Lewis, a retired educator, travels to Albany and Columbus frequently for appointments and would love to eliminate the additional time it takes for roundtrips there.
“In fact, I just had a health scare, but I had to go to have a CT scan there. Then I had to go to Sylvester [Georgia] to a hospital there because they didn’t have enough space there for me for that particular thing,” she said. “I would have had that CT scan right here in Cuthbert, if it was open.”
When the hospital closed, the doctors left, too. Until about a year ago, the town had no doctors, despite Care Connect, an urgent care clinic, opening immediately after the hospital closed in 2020. Jenkins and residents hope the draw of a hospital will bring more jobs, affordable housing, and food options into the town, which is racially divided.
“With the white there and the Black here, you can’t get nothin’ done. We don’t go to church together, but at least we can have some common ground when it comes to the community and for the betterment of all the citizens,” said Cuthbert council member Sandra Willis.
The hospital is the only issue that they’re united on, she says. The majority Black county commissioners, all-Black city council, and Randolph County Housing Authority have worked together to figure out a solution.
They’ve been able to get the attention of their state and federal officials. After four years, they have a plan.
Earlier this year, U.S. Rep. Sanford Bishop and Sens. John Ossoff and Raphael Warnock requested congressional earmarks to develop and reopen Southwest Regional. They secured more $4 million from the USDA Community Facilities Program and more than $2 million from HUD for the Randolph County Hospital Authority to move forward, according to a spokesperson in Bishop’s office.
There’s no date for when a hospital, or some version of it, will be reopened in Cuthbert. Will critical access, rural emergency hospital, or freestanding emergency department work best? County officials contracted with a third-party to conduct a feasibility study to decide what route to go with the hospital.
“What we hope is to have an emergency room so we can get ‘em stabilized,” State Rep. Gerald Greene said in a phone call. “We’re hoping this is going to work, but we’ll have some [inpatient] rooms. That’s our plan.”
In Brownsville, it took six years to find a solution. In attorney Banks’ eyes, it was all “pure luck.”
On a recent tour of the hospital, Banks — who is now CEO of Haywood County Community Hospital — pointed out a bed that displayed colorful LED lights with symbols, advanced technology that checks oxygen levels, weight, and heart rates.
“If a [patient] gets too close to the edge, the alarm goes off. So, the nurse at night – rather than waking someone up – they can come out and look at those lights.”
He credits Braden Health, the hospital management group that took over the hospital. As counsel for Haywood County, Banks would take prospective buyers on “a tour with a flashlight” because the building was boarded up. None of the deals panned out — until 2020 when they met Dr. Beau Braden, an emergency medicine specialist and co-founder of Braden Health. The county officials agreed that Braden Health could take if they improved the property and ran the facility as a full service hospital.
Two years later, they reopened Haywood Park Community Hospital, under a new name: Haywood County Community Hospital. They downsized to nine in-patient rooms and have a staff of 80 employees, all from Brownsville or neighboring communities.
In addition to an emergency room, they have an urgent care walk-in clinic, pharmacy, mammography, ultrasound, and radiology department. Despite the new infrastructure and quality, Banks averages about five patients a day, and about 25 patients in the ER. But, there have been times when they’ve had to send patients to other facilities because they are full, he said.
Residents stop by often for the handprint ceramic tile wall in the main entrance of the hospital. In the 1990s and early 2000s, kids in Brownsville painted these tiles. Many people come back to find their handprint. They built a conference room so local organizations can meet. They also eat at Annie Mae’s Cafe, a soul food restaurant in the hospital named after Tina Turner and run by two local cooks who lost their restaurant during the pandemic.
Banks, the mayor and residents, are optimistic about the hospital’s future. In fact, they’re planning to expand, adding things like a physical therapy section. They expect more traffic, especially with the opening of Ford’s Blue Oval mega facility.
“Ever since we opened the inpatient side, we’re breaking even. We’re profitable and growing more every month,” Banks said. “Even if Brownsville stayed the size it was, we’d be fine.”
Staying on top of the accounting, rural health-related policies and regulations, and making sure insurance providers pay is the key to being sustainable, Banks says.
Beyond federal dollars, there’s a need to expand Medicaid, increase Medicare payments, and incentivize health care professionals to work in rural areas, rural health experts say. They also advocate for health equity, specifically on better pay systems for rural hospitals and ensuring those investments focus on communities that have “faced historical and contemporary challenges of racism.”
Ultimately, everyone has to work together — government officials, local agencies and the residents.
“People are dying. Not because the hospital is there or not there. It’s because we’ve not taken control. We’re accepting a lesser quality of life and a shorter life expectancy,” Rawls said. “True systemic change is a grassroots effort, but you will need people from the top pushing legislation that’s going to allow rural hospitals to survive or reopen.”
The post Healing a Dark Past: The Long Road to Reopening Hospitals in the Rural South appeared first on Capital B News.
It has been little over a year since Martin County, a rural community of 22,000 in eastern North Carolina, lost its hospital.
Martin General served generations of local families during its seven-decade run in Williamston, the county’s seat of government. People born at the hospital returned to witness the births of their own children and grandchildren. Some lifelong residents drew their first — and last — breaths at the 43-bed facility.
But as the county’s population began to dwindle in the 1990s, so did the for-profit hospital’s revenues. Teetering on the brink of bankruptcy, Martin General attempted to cut costs by discontinuing maternity services in 2019 and shuttering its intensive care unit in 2021.
The changes weren’t enough to keep the struggling hospital afloat. In August 2023, Martin General announced it would close after 73 years in business.
“Though this is a very emotional decision, Martin General Hospital is no longer accepting patients, including emergency patients, and the hospital has filed for bankruptcy,” Quorum Health, the hospital’s owner, said in a statement at the time, adding that Martin County’s Board of Commissioners “chose not to respond” to a proposal that would have transferred ownership of the facility to the county.
In a Facebook post disputing the company’s version of events, the county wrote that commissioners had met to discuss the terms of the transfer and instructed their attorney to “ask for additional information” on Aug. 1. The county said it learned the next day that Quorum had “closed the doors of Martin General.”
Citizens of Martin County, where the median household income is only $44,799 a year ($21,387 less than the statewide average), responded to the closure with concern and outrage. Losing Martin General meant they would be forced to travel more than 20 miles to the nearest emergency department in neighboring Beaufort County. They wondered how their elected leaders could allow this to happen.
“Do you really care, commissioners?” Verna Perry, a longtime Williamston resident, asked during the board’s meeting in April. “If you cared, you would do something to get us a hospital here.”
But the county had been working for several months on a complex plan to resurrect Martin General — a plan that, if successful, could become a blueprint for other rural communities where hospitals have closed.
When Congress passed the Consolidated Appropriations Act of 2021, it created a lifeline for struggling hospitals in rural areas, allowing small facilities with less than 50 beds to convert to so-called “rural emergency hospitals.”
In exchange, the hospitals would receive millions in annual funding from the federal government. They would also be eligible for increased reimbursement rates for some outpatient services covered by Medicare.
The catch? While rural emergency hospitals are required to provide 24/7 emergency care, they are not allowed to offer inpatient services.
These inpatient services, which range from elective surgeries to childbirth, tend to make up a large share of traditional hospitals’ revenue. A 2018 study by the American Hospital Association found that inpatient services accounted for more than half of all revenues reported by community hospitals from 1995 to 2016.
But it’s a trade-off that some hospitals appear willing to make. Twenty-nine facilities across the U.S. have converted to rural emergency hospitals since the program launched in January 2023, according to data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.
Unlike Martin General, those hospitals were still in business when they made the switch. Officials in Martin County, however, believe the hospital can be reopened using the rural emergency model — something that has not been attempted anywhere else in the nation.
“As far as we can tell, this is really the first such situation in the country,” Ben Eisner, interim Martin County manager, said in an interview with NC Health News. “Trying to navigate that has certainly been tricky. It’s taken us a number of months to work through some of the regulatory issues of opening a closed hospital as a rural emergency hospital.”
The hospital will benefit from a 2015 law passed by the General Assembly that makes it easier for a shuttered hospital to get back into business if the reopening takes place within a two-year window after the initial closure.
Dawn Carter, health care consultant for Martin County, said a study conducted by her firm in early 2023 found that the rural emergency hospital program would “be a really good fit” for Martin General, whose financial difficulties were by then well known.
The problem, she said, was that the North Carolina General Assembly had yet to adopt a state budget with language allowing the state’s hospitals to participate in the program. Quorum closed Martin General in 2023 before a budget finally passed — months behind schedule — that October.
“We were thinking about it before the hospital closed, so we just continued to pursue that option,” Carter said in a video interview. “It being closed raised a lot more questions. But unless the feds told us, ‘No, you can’t do this,’ we were going to continue to pursue it.”
Earlier this year, the Centers for Medicare and Medicaid Services confirmed that Martin General could reopen as a rural emergency hospital, clearing the first and arguably most important hurdle in the county’s path. But Carter said there are still obstacles left to overcome.
The aging facility, which Eisner described as having been “cobbled together over the years,” must pass an inspection to ensure it meets CMS’ requirements for the program. After that happens, the county will need to solicit proposals from providers who are interested in running the hospital.
Eisner said the timeline for completing those steps is uncertain. He and Carter declined to share their predictions for when Martin General might actually reopen.
“I don’t want to give false hope to that community, so we’re telling them what we know when we know it,” Carter said. “And right now, it’s just not determined.”
Perhaps the biggest consequence of Martin General’s closure has been the loss of the hospital’s emergency department, which averaged about 16,000 visits a year.
Residents in need of emergency services must now be transported to hospitals in neighboring counties. Eisner said the longer drives have put increased strain on Martin County’ s small staff of paramedics and ambulance drivers.
“Certainly, if you’ve watched any of our board meetings over the last several months, there’s been a lot of citizen unrest and concern about what happens in the future,” he said. “But I think it’s been kind of documented that the greatest impact has been on EMS and local emergency services, which are seeing increased distances, wait times and costs.”
Calls for emergency services have also been on the rise, according to Carter.
“Because of transportation challenges in Martin County, it’s hard enough to get a ride 10 minutes down the road to the hospital,” she said. “But if you’ve got to go 30 minutes, you’re going to call EMS — whether you really need that care in transit or not.”
Underscoring the need for a local emergency department is this year’s County Health Rankings report from the University of Wisconsin Population Health Institute , which rated Martin among the least healthy counties in North Carolina.
Martin County has higher rates of adult obesity, adult smoking, sexually transmitted infections and premature deaths than the state and nation, according to the report. The life expectancy for county residents is about 72 years — four years less than the statewide average.
Martin County is far from the only rural community that has lost its local hospital in recent years.
According to the Sheps Center, nearly 150 rural hospitals across the U.S. have either closed or drastically scaled back their services since 2010. Twelve of those facilities are in North Carolina, the center reported.
In addition to being the first hospital in the nation to reopen as a rural emergency hospital, Martin General would be the first hospital in the state to receive the designation. Because the program is not open to facilities that closed before 2023, it cannot be used to bring back the state’s other shuttered hospitals.
But Martin County’s experience could provide a road map for other rural communities facing a similar situation in the future.
“If the dynamics are consistent with what the community needs and wants, then I think that this is certainly a viable option for them to consider in order to maintain access to high-quality outpatient care that is vital to a rural area,” Brock Slabach, chief operations officer for the National Rural Health Association, said in a phone interview. “When we look at surveys of individuals in rural communities and what they value about their health care system, emergency services tend to be at the top of the list.”
Slabach said the rural emergency program was “never designed to be an answer for all the problems of rural health.” The program can, however, be a “valuable tool in the toolbox for communities to consider to maintain and hopefully revitalize their health care services.”
“I applaud this county for taking a look at this program and having people interested in reopening a closed facility to restore that access to care that is so vitally needed,” he said.
Still, Slabach acknowledged that the provider that eventually takes over the hospital will have their work cut out for them.
“It’s not easy to run any facility, let alone reopen one that’s been closed, because you’ve got to create everything from scratch,” he said. “It takes time to gather a team with the expertise to be able to navigate the reopening of a facility, never mind one that is opening as a new provider type like a rural emergency hospital.
“This could be a journey, and it will definitely take some effort on their part to get that done.”
The post Rural NC county pursues experimental plan to revive shuttered hospital appeared first on North Carolina Health News.
Rain in July helped most NC farms recover from June drought, but corn crop devastated. Some counties had too much rain and some not enough.
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On a street corner east of Durham’s downtown, Cheryl Riley spotted a woman sitting on a ledge outside a grocery store, her upper body bobbing back and forth.
Riley, a Durham County paramedic, pulled over her Ford Expedition with bright blue and yellow markings and asked the woman if she could take her vitals. After getting a go-ahead, Riley checked her blood pressure and oxygen levels.
This was not a stop in response to a 911 call. Riley criss-crosses the city as part of the county’s special Community Paramedics program, and she sometimes focuses on areas where drug users congregate.
“We do not judge,” Riley told the woman after removing the blood pressure cuff and pulse oximeter. “But can you tell me what you took?”
“Fentanyl,” the woman responded.
“Do you trust your dealer?” Riley probed further.
“I don’t trust nobody,” her patient responded.
Worried about a potential overdose, Riley gave the woman some water and asked if she could call for an ambulance. After initial resistance about being stuck with a big medical bill, the woman acquiesced when Riley comforted her and promised to check on her later.
“That usually doesn’t happen,” Riley told NC Health News. Often, Riley said, the people she encounters in nonemergency situations on her usual routes are wary of being taken to the hospital.
Riley is one of two community paramedics in Durham County. The program began in 2017 to serve people with substance use issues, mental illnesses and chronic medical conditions through home visits, community check-ins and their professional connections with health care centers.
The goal is to cut down on emergency department visits, provide follow-up care after hospital stays and take essential information and medications to patients that some refer to as “frequent flyers” for their numerous ER visits. These specially trained paramedics serve as bridges to clinics, detox centers and other facilities that provide nonurgent care. They also help the elderly, disabled and others make their homes safer, such as pointing out measures they can take to better prevent falls, and help organize transportation to medical appointments.
In recent years, community paramedics have made it a priority to distribute naloxone kits and share recovery resources for people with substance use disorder.
“It’s this many-armed approach that combines both health care with social health and community outreach,” said Riley, who’s been in her current role in Durham for two years and worked in Orange County emergency management before that.
NC Health News joined Riley in early July for part of her rounds and agreed not to disclose identities of the people she stopped to check on.
Durham County is not the only North Carolina entity with a community paramedic program.
McDowell County touted itself as one of the earlier programs in the country and among the first in rural NC after launching in 2013 with funding from the Kate B. Reynolds Charitable Trust.
Others have launched more recently with some of the $750 million allocated to the state as part of the $26 billion multi-state settlement with pharmaceutical manufacturers and distributors accused of stoking the opioid crisis.
Edgecombe County started a program in 2023. Onslow County, home to Camp Lejeune and Jacksonville, has a large community paramedic team with slots for eight full-time workers. The Johnston County Emergency Medical Services Division has a community paramedic program, as do Davie County, Caldwell County, Orange County, Yancey County.
Nash UNC Health Care realized that it could cut down on some of its repeat emergency department visits by sending community paramedics out for home visits with blood sugar monitors to help people with diabetes, bring medication information and help them navigate medical issues outside a physician’s direct care as vulnerable patients recuperate from a hospitalization. Cape Fear Valley Health did the same thing.
What distinguishes community paramedics from traditional paramedics and emergency medical technicians is their ability to follow up with patients and help them find longer-term treatment options for such problems as substance use disorder, a process they call “bridging.”
Over the past year, they’ve started using medications for opioid use disorder as part of treatment. These synthetic opioid medications like buprenorphine and methadone help people manage withdrawal symptoms and start on the pathway to recovery, research shows.
Many of the people working in harm reduction and health care, Riley included, believe these medications are a key part of treating addiction as a chronic disease.
Deaths due to opioid overdoses have been rising in North Carolina, including in Durham County, where opioid-related deaths tripled from 2019 to 2022. NC Health News has reported extensively on the opioid epidemic, its impact on North Carolinians and how counties are responding to the crisis.
Public health officials have described opioid deaths as happening in three waves, with the third and most recent wave associated with a decade-long increase in overdose deaths from synthetic opioids, most notably fentanyl.
Anjni Joiner, medical director of Durham County Emergency Medical Services and a physician at Duke Health, is part of a growing group of experts observing what they describe as “a fourth wave” from fentanyl being consumed with other drugs — cocaine, methamphetamines and marijuana — often unknowingly.
“People who are not even trying to take opioids … are overdosing,” Joiner said.
One such case serves as a cautionary tale for Riley. She had just started her job in Durham and encountered a woman who had been smoking marijuana to relieve symptoms from the chemotherapy she was getting while battling breast cancer. Unbeknownst to the woman, the marijuana was laced with fentanyl, and she overdosed. While paramedics were able to revive her, Riley believes it underscores the risks inherent to the drug supply from the streets.
“We’re seeing a lot more of that — where people think they know what they are taking, but their drugs are contaminated,” Riley said.
Durham data underscores that trend. Joiner said that before the proliferation of fentanyl in recent years, they were seeing, on average, 40 to 60 overdoses per month. Now that monthly average is 80 to 100 overdoses with peaks in the summer months. In July 2023, Durham County emergency medical services responded to a record 102 opioid overdoses — which Joiner and others within county emergency medical services attributed to fentanyl contamination.
When paramedics respond to a suspected opioid overdose after a 911 call, their first step is to administer naloxone, which is known by its brand name, Narcan. Opioids cause the slowing and shallowing of breathing — which can lead to respiratory failure. Naloxone reverses these effects, but it also produces withdrawal symptoms.
These symptoms such as sweating, anxiety, diarrhea and vomiting can be serious, according to Riley. Given that, she disputes the narrative that people with opioid dependence can simply quit “cold turkey.”
Medications like buprenorphine help manage withdrawal symptoms and, if administered regularly, have been shown to improve people’s chances of recovery. Durham County paramedics began administering buprenorphine in June 2023. In the ensuing 12 months, 36 people have been started on buprenorphine out of 818 overdose-related calls, according to data shared with NC Health News.
Treatment for ten of those people began in June 2024, the most in a single month. Joiner sees that as a positive sign that Durham emergency service providers are making treatment more available. “It just takes time to really get integrated in the community,” she said.
The slow start is also a reflection of program capacity. When the program began, only community paramedics and paramedics who volunteered to get special training were allowed to administer buprenorphine. As of March, all Durham County paramedics have been trained. Each ambulance is now stocked with the medication, according to Joiner, allowing for administration of buprenorphine whenever emergency services responds to a call.
Joiner said the emergency teams have had the most success with getting people on buprenorphine a few days after an overdose.
“They’re pretty overwhelmed. It’s a near-death experience, and so we find that when we follow up with them in the next couple of days, [people] are more open to starting on the medication,” she said.
While the goal is to get people into long-term care where they can receive medications regularly, that doesn’t always happen right away. During those lags, community paramedics can provide follow-up care and daily administration of buprenorphine for up to seven days. Often, they call their patients ahead of time and schedule a set meeting point and time to administer buprenorphine.
“I think we’re really innovative in that respect,” Joiner said.
Over the past five years, North Carolina has been investing more in medications for opioid use disorder. Through its Bridge MAT program — MAT being the old acronym for medication-assisted treatment for substance use disorders — the state Department of Health and Human Services funds county emergency medical services to use buprenorphine to treat opioid use disorder.
The first two counties in the Bridge MAT program were Onslow and Stanly, which received grant funding in 2019. In 2023, the funding was expanded to eight more counties, including Durham. Recipients of these grants, crucially, must invest in a community paramedics workforce to administer buprenorphine.
“People are interested in what we’re doing. They like the idea that there’s something out there that’s supportive, someone that they can call,” said Helen Tripp, program director of the community paramedics program. The Bridge MAT grant has helped sustain Durham County’s community paramedics program and keep it accessible for all residents.
“They don’t have to worry about getting a bill because we don’t charge for what we do,” Tripp said.
The program is about to grow. Tripp said two more community paramedics will be added in Durham County, bringing the total to four. There also are plans to tap into another grant to hire peer support specialists — trained staff who have lived through managing substance use disorder and can dispense their wisdom.
Riley believes the new personnel will help them keep up with the high demand for their services. Between active dispatches and follow-up visits, her 12-hour shifts tend to be very busy.
“We are health care…but we’re also filling in this home care position. We’re doing a little bit of social work, we’re doing a little bit of case management, we’re working on the opioid overdose problem,” Riley told NC Health News.
But she also appreciates the freedom offered by the community paramedics program. Driving between appointments, Riley checks in on familiar faces — many of them unhoused — as she hands out water, food and naloxone kits. Some of them recognize her from previous visits.
Riley sees this “combination of medicine and helping better your community” as central to community paramedics team missions.
“Durham has clinics, Durham has resources, Durham has opioid response … but the problem is getting those resources to the people who need them,” Riley said.
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Katherine Farris has been an abortion provider for more than 20 years, and she says that this past year has been the hardest of her career — by a long shot.
Not her first year of practice when everything was new. Not the year she stepped into the role of chief medical officer at Planned Parenthood South Atlantic to supervise clinic operations across North Carolina, South Carolina, Virginia and West Virginia. Not the years she navigated COVID protocols to keep her staff and patients safe.
The last year stands out above all the rest, as challenges escalated to a new level.
That’s because a year ago today, North Carolina’s new stricter abortion law took effect, significantly diminishing abortion access in the state. The time frame for seeking most abortions dropped from 20 weeks of pregnancy to 12 weeks, and the law added an in-person requirement for state-mandated counseling at least 72 hours before an abortion.
Farris has had a front-row seat to the upheaval caused by the change in law: Clinic staff frantically reworking operations to comply. Physicians stretching themselves thin to see as many patients as possible — knowing they can never meet the full demand. Patients desperately pulling resources together to book an appointment — often driving hours for care. Clinics turning patients beyond the state’s limits away without knowing whether they will be able to travel elsewhere.
“These aren’t just numbers to us,” Farris said. “These are real human beings that sit in front of me in my office, and I see the burden this has put on them.”
No longer providing care beyond 12 weeks or practicing to her full capabilities has been a seismic shift that’s been difficult for Farris to adjust to. She gets a glimpse of the more weeks of care she used to be able to provide in North Carolina when she practices in Virginia, which allows abortions up to 26 weeks.
“Depending on where my feet are planted, that’s what determines the care I can give,” Farris said. “It’s not my skills. It’s not the support staff. It’s not the equipment. And it’s certainly not what the patient needs. It’s just where my feet are planted.”
Despite the new restrictions, abortion volume in North Carolina has not dropped significantly since Senate Bill 20 took effect a year ago on July 1. In large part, that’s due to the efforts of abortion clinics, providers, abortion funds and other support networks that have worked to keep abortion accessible. Patients themselves have also gone to great lengths to overcome the increased obstacles to access care.
“Patients are incredibly resilient and resourceful,” Farris said. “But every day, I am angered that they have to be. They should not have to be so resilient. They should not have to be so resourceful. They should be allowed to get this care from a provider they already know and trust in their own community.”
Calla Hales, executive director at A Preferred Women’s Health Center, which operates two abortion clinics in North Carolina, tries not to think about the day a year ago when abortion access in the state changed.
Newly gained Republican supermajorities in the state General Assembly — a result of one Democrat’s abrupt party defection — swiftly passed the state’s stricter abortion law, Senate Bill 20, over the objections of medical professionals and Gov. Roy Cooper’s veto.
Hales said the first weeks were particularly tough and frantic.
“I really remember most like not sleeping for days on end,” she said. “To be quite honest, there is a stretch of time that last week of June and the first couple weeks of July where I was probably sleeping like five hours a week.”
She knew the stakes were high. The clinic needed to quickly change its operations to comply with the law and serve as many patients as possible.
Physicians and abortion clinic staff reworked processes, patient flow and schedules. They trained staff. They learned the new state-mandated counseling script and reporting requirements.
“You’re having to figure it out on the fly,” Hales explained. “Patients don’t stop needing care to provide you with the time to stop and figure out how to address practices to better change to the scope of these new rules.”
Amber Gavin, vice president of advocacy and operations at A Woman’s Choice, an abortion provider with three clinic locations in the state, said clinics grappled with how to accommodate twice as many appointments to provide abortion care for the same number of patients. Patients coming in for two in-person appointments strains the physical space within the clinic and the staff’s time.
Even now, with processes worked out, it continues to be an intricate balance of accommodating the increased volume of people in and out of the clinic, especially given the ramped-up pressure of the reduced time frame that abortion procedures can take place in North Carolina, Gavin said.
As a result of the new requirements, abortion volume in the state dropped substantially during the months immediately after the implementation of Senate Bill 20, according to data from the Guttmacher Institute, a national organization that tracks trends in reproductive health. However, the number of abortions provided each month has since ticked back up, returning to volumes in line with pre-Senate Bill 20 numbers. In March, North Carolina provided about 4,030 abortions — the highest monthly volume since the law took effect last July — according to the latest data available from Guttmacher.
All three abortion clinic providers in the state that NC Health News spoke with said they’ve added days of abortion care to their schedules. They’ve also gotten creative with some of the appointment offerings, adding some later in the day, as they recognize that some patients can’t make it to morning appointments with the travel distances they are facing. Planned Parenthood has even expanded the locations where it provides medication abortion; the Durham health center started the service last month, and the Greensboro location is scheduled to start in mid-July.
A year later, some days can still be just as frantic as those early days, Gavin said. Phones ring off the hook. Patients’ emotions boil over — and staff’s can too. Clinic staff increasingly have to expand beyond providing medical care, doing more coordination to help patients navigate to other states to receive care past the 12-week North Carolina limit.
The abortion law also remains in flux, with two lawsuits challenging certain requirements that lawmakers implemented. That keeps abortion providers on their toes awaiting any decisions that further affect how they can provide care.
For instance, last month, U.S. District Judge Catherine Eagles in Greensboro issued a judgment that struck down several of North Carolina’s rules on dispensing medication abortion pills. Lawyers for Republican legislative leaders promptly appealed the judge’s decision.
Abortion providers say the most burdensome part of the law is the requirement that a patient go to an in-person appointment for state-mandated counseling at least 72 hours before an abortion. Previously, this pre-procedure counseling could occur over the phone or online.
The new requirements mean that patients must visit clinics at least twice — and many need to travel long distances to reach one of the state’s 14 abortion clinics spread over nine counties. The additional appointment means extra time off work and more travel, hotel stays and child care costs.
“People don't have extra money lying around that they can just stay in a hotel for three days,” Farris said. “They don't have someone to watch their kids for three days. They can't get time off of their job for three days. It's really incredibly cruel, especially because it is so medically unnecessary.”
One of the biggest barriers to abortion access is cost, said Justine, a Carolina Abortion Fund staff member who requested that NC Health News only use her first name for security reasons. Garnering the resources for a two-visit process under Senate Bill 20 can be even more of a challenge as nonmedical costs for gas, flights, hotels, child care and lost wages accumulate. That’s reflected in the sizable uptick in the number of callers seeking financial assistance to cover these practical support costs to get to their appointments, Justine said.
Justine said Carolina Abortion Fund, which helps patients pay for part of their procedure, is distributing more funding per month than before Senate Bill 20, but it is only able to meet about 40 percent of caller demand. In March, the latest data Carolina Abortion Fund could share with NC Health News, the organization distributed more than $70,000. In comparison, in March 2023, the organization distributed about $45,000.
Every month — typically after around 10 business days, depending on call volume — Carolina Abortion Fund exhausts its monthly funding, Justine said. When that happens, volunteers and staff members work with callers to help figure out funding, referring them to other funds and resources.
Farris says the financial and logistical challenges caused by the increased restrictions are pushing abortion care later in pregnancy. For example, Farris said she recently saw a North Carolina patient who came in for her initial appointment at 11 weeks pregnant. But by the time the patient could obtain her abortion procedure, she was 15 weeks pregnant — past the 12-week limit. Ultimately, she took a bus to Virginia, where Farris provided her abortion care.
Guttmacher data shows that in 2023, a total of 1,720 North Carolinians obtained abortions in Virginia — the most popular out-of-state choice.
“When they write this law, they just assume everyone will magically know they're pregnant sooner and come in right away,” Farris said. “But the human body doesn't work that way, and people's life circumstances don't work that way. So instead, what happens is while some people are coming in much sooner, we also, on the other end of the spectrum, see people push later and later in pregnancy by the time they can get the resources.”
Others may be unable to pull the needed resources together. Clinics say a number of people don’t make it back for another appointment after the in-person counseling.
The additional logistical hurdles can also create a more trauma-filled experience, said Simran Singh Jain, an abortion doula in Durham. Over the past year, she’s worked with about 30 people seeking abortions. The time crunch is forcing people to move more swiftly to access care, potentially neglecting their own emotions as they stay hyperfocused on navigating the logistics.
“We're having much more of those logistical conversations, and so people don't really have the opportunity to actually process what is a very vulnerable moment in their lives,” Jain said. “Because of that, I'm finding a lot of people are reaching out to me months later for the support that they were not able to take at the time because they were so focused on that logistical piece — just how challenging it is to get an abortion fundamentally — versus being able to actually take the time to navigate their own emotions about it.”
And a handful of patients continue to show up to clinics thinking they are getting an abortion that day, and they are devastated to learn they can’t — caught off guard by the two-appointment requirement.
Hales said these people often assume it’s a clinic policy rather than state law. She’s seen people plead to have the abortion on the same day — saying that they’ve already put much thought into the decision and don’t need another waiting period — but her hands are legally tied.
In other cases, said Rachel Jensen, an abortion provider in the Triangle, she’s cared for patients with nonviable pregnancies who have questioned why they have to wait 72 hours — the longest waiting period in the country.
“I don't have a good answer,” she said. “It's because of the state law. And it's a really sad thing to say that your medical practice is dictated not by medical best practices, but by essentially arbitrary policies.”
NC Health News will be continuing to cover the effects of increased abortion restrictions in the months ahead and the best way for us to do that is with your help — hearing concrete examples of how you are navigating the new law. Have you been affected by new abortion restrictions as a medical professional or a patient? NC Health News is interested in hearing your experience.
The post One year into new abortion limits, N.C. patients and providers struggle to shoulder the load restrictions bring appeared first on North Carolina Health News.
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