Siri Nelson officially takes over as CEO of Marshall Medical Center at the end of January, concluding a six-month transition to learn from outgoing leader James Whipple, who retired after 16 years in the position. Nelson is responsible for overseeing a 125-bed hospital in Placerville and several outpatient facilities and 1,800 employees for the organization, which was founded in 1959. Comstock’s spoke to Nelson about her organization’s efforts to provide quality health care services to residents of El Dorado County.

You have nearly 30 years of experience in rural health; what makes rural health​ especially challenging?

Partly it’s the lack of population density. It’s difficult for people to get access to care when they’re all spread out all over the place. That’s one of the things we love about living in a rural community, but it’s also one of the things that makes it more challenging. I remember when I first moved to a rural community — I grew up in the Bay Area; I really didn’t have a clue — and then I moved to a small town, and I was like, now I get it: You move out into the sticks and you drive. Because Safeway is half an hour down the highway, it’s not 10 minutes around the corner. … It’s also that there aren’t a lot of large employers, so there’s not a (large) commercial base. One of (the challenges) about providing health care is that specialists — for instance, like neurosurgeons — have to have a significant population base to support that because, thank God, not everybody is going to need a neurosurgeon. … In rural (areas), you don’t have that population base to be able to support specialists. So we’re always trying to balance what’s the right mix between providing it locally or getting access to somewhere else that can do it.

Has Marshall found it challenging to recruit doctors to a rural setting, and what does Marshall do to make itself attractive to candidates?

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What do you want to tackle first under your governance?

Everything, but you can’t do everything all at once. Right now, what I’m working on is creating the infrastructure — you have to set up the processes internally so that the changes can be made. … It’s making sure we have the right team; I’m very fortunate that the senior executive team is amazing. … Sometimes you walk in and think, “OK, so I have to start over.” That is absolutely not the case here. For me, it’s more about process and structure than it is about individuals. That’s the first step — to build a steady base. 

Marshall is an independent hospital. How does this affect the care you provide?

One of the things I’ve always admired about Marshall is its ability to maintain its independence, and the way you do that is to be a good steward of the financial resources of the organization, because if you get into trouble financially, that’s when you start looking for somebody to come bail you out. Marshall has been … able to build and invest back into the company, so that’s a big positive. The other thing that helps us is we can be much more nimble than a large organization. The analogy is always the battleship: We’re not an aircraft carrier; we’re probably a battleship size. We’re certainly not a flotilla — a big bunch of ships that all go somewhere together. But we’re still a battleship, so it still takes organization and energy to change direction, but we can be much more nimble than larger organizations. … That is the biggest advantage of maintaining our independence.

Marshall Medical Center includes a hospital and several outpatient facilities and is affiliated with 200 practitioners. Do you anticipate areas of growth or have you identified areas that have been underserved that you’re trying to target?

We’re always looking at that. (We’re) developing a strategic plan for the organization … that’s really going to inform what makes the most sense of where we go next and how we grow. El Dorado County is fortunate that it’s growing pretty rapidly. The challenge is that there are only limited resources, and there’s only so many things we can do at once, so what makes the most sense for us? … The last formal strategic plan was done in 2015. … What we’re doing now isn’t going to be a radical change from before. What I’m really looking for is alignment and focus out of that process. So we’ve been going down this road — we’re not all of a sudden going to take a hard right and go in a different direction. 

Marshall has completed its “2019 Community Health Needs Assessment” report. The results found three needs for Marshall’s service area: substance use, mental health and access to care. Can you tell us more about those needs?

I’m going to talk about substance abuse to start with. We have a (Clinically Assisted Recovery & Education Services, aka CARES) clinic, which provides (medication-assisted treatment). It’s really about opioid reduction, so we can take patients and community members who are addicted and help them through medication-assisted treatment to help them have a functioning life. We are one of the first organizations (in California) that I’m aware of that’s doing this kind of investment in opioid reduction. The next thing we’re going to be working on is looking at how our providers subscribe opioids. I was at a meeting where we talked about pain management for opioid-naive patients … (meaning) someone who doesn’t take that stuff. But then (that person) breaks a leg — what’s the appropriate dosing for someone so that we don’t end up inadvertently addicting patients? It’s really about how to not start people, but also if they have a problem, to help them manage it and have a normal life. (The CARES program that opened one year ago has) a 94 percent rate of success. So after one year in the program, 94 percent of the patients are still in it, which is unheard-of amazing, especially for addictive-type services — the fallout rate is usually more than half.

Behavioral health: We actually have two psychiatrists as part of our medical foundation, which is really amazing. I’m used to working in rural communities, and access to psychiatric care or mental health services is (often lacking). … We also have a psychiatrist who helps with individuals who come into the emergency department, who are inpatients who maybe have a psychiatric issue — because we can manage the medical issue, and the psychiatrist can help us manage the psychiatric issue, so we’re treating the whole person. Those are the two big things we’re doing at this point, but something we need to think about is how can we expand that.

The medical foundation has done a great job of improving access over the last couple of years. One of the key indicators is how soon a new patient can get an appointment. It was quite a long time, and (now patients) can get in within days most of the time. … I think with the health-needs assessment, it’s a little broader — it looks at access to things like transportation and time off work and (if the patient has) insurance. It’s a little broader than how a health system looks at access. Not that all those things aren’t important, because they are.

Anything else you want to mention about serving a rural customer base?

We’re almost 80 percent government pay (i.e., Medicare and Medi-Cal). We don’t have a lot of commercial insurance up here, so it makes the financial part of this challenging. There’s not a lot of big employers in the county. … It’s a hard market for insurance companies to be in because the population isn’t very big, so not a lot of them want to come into a rural community because there’s not … enough patients or residents or members to make it worth their energy.  … 

The hospital is absolutely an economic driver for the community. … We’re pretty big by rural standards. We have good-paying jobs; we have about 1,800 employees, and that creates a lot of economic engine for the county, but it’s not our role to work with (the county) to build this or that or help incentivize this employer to come here. What we can do is make it attractive for someone to be here because we have great health care. We’re kind of like the school district that way.

Marshall Medical Center celebrated its 60th anniversary last year. Can you tell me about the start of the organization?

It was part of the Hill-Burton Act (passed by Congress in 1946), and it was a federal program that said if (a facility) kicked in this much money, the federal government will pay this much money, and then you had to work off the grant by providing uncompensated care. A lot of small, rural hospitals got started in the Hill-Burton era. The (local) community was doing blood drives and bake sales, and the auxiliary was out washing cars … to raise enough money just to be able to meet the requirements of that Hill-Burton grant (to raise $411,000), and so it really was the community pulling together to make this organization possible, and I think that goes deep into our roots.