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When you think of lobbyists, visions of meetings in smoke-filled rooms come to mind. The stereotypical special interest advocate is a fast-talking influence peddler with a fat cigar and envelopes full of money.

In reality, many of the people who meet with legislators on behalf of hospitals are regular folk. One might be, for instance, a sheep farmer in rural Idaho like Margaret Soulen Hinson. A snapshot of her out on the ranch in a hooded sweatshirt belies the fact that she is an active, effective spokesperson on behalf of Weiser (Idaho) Memorial Hospital, the small critical access hospital in her town of 5,000.

For Hinson, working with lawmakers is a key part of her role as a board member and crucial to keeping the hospital open. She believes Weiser Memorial is one of the basic services that keeps a small town like Weiser alive. "For towns to survive they have to have a strong health care system and a strong education system," she says. "Maintaining health care within our community is critical for serving our people."

Hinson's work advocating for the hospital won her an American Hospital Association Grassroots Champion award for 2010. The award singles out one hospital leader from each state who, over the previous year, "effectively delivered the hospital message to elected officials, helped broaden the base of community support for hospitals and advocated tirelessly on behalf of patients, hospitals and the community they serve," according to a letter of appreciation from AHA President Rich Umbdenstock. The winners also receive local recognition.

Grassroots Champions are chosen by each state hospital association. In 2010, three of the winners were not hospital administrators or government relations people, but trustees like Hinson. They include Cliff Stewart, a retired businessman who sits on the board of Calvert Memorial Hospital in Prince Frederick, Md., and Lynn Harris, a retired dentist who is chairman of the board at Grande Ronde Hospital in La Grande, Ore.

It makes sense that state hospital associations increasingly are looking to boards when it comes time to visit legislators and write letters to support their issues, says Carmela Coyle, president and CEO of the Maryland Hospital Association and a former executive with the AHA. "There are no better spokespeople for our hospitals than our volunteer trustee leaders who guide them," says Coyle. "Their perspective comes from the community. When you come at issues from the perspective of trustees, it's in the spirit of collective good: 'What can we do to improve care in our state?'"

Many of the top leadership positions in the Maryland Hospital Association are filled by trustees. The chairperson and a majority of officers are member hospital board members. "Our trustees are very involved and engaged in the work of the organization, and that includes our grassroots work," Coyle notes.

Protecting the Small, Rural

Of the three trustees who received Grassroots Champion awards, all happen to come from rural areas, working on behalf of small or very small hospitals for whom public policy decisions can make the difference between surviving and shutting down.

Weiser Memorial, for example, is considering affiliating with a bigger hospital for better financial security in the face of trends that require big financial investments — such as health information technology systems — and reduced income as state Medicaid budgets are targeted by budget cutters in state capitals. Weiser, a public district hospital, already has a connection with St. Luke's Hospital in Boise, which provides some management expertise.

Harris' hospital, Grande Ronde, is just two hours away, across the Oregon border, and shares many of the same challenges.

A nonprofit community organization, Grande Ronde is in good financial shape for a 25-bed critical access hospital, the result of strong management over the years by its longtime president and CEO, Jim Mattes, says board chair Harris. Attaining this level of stability requires building strong relationships with legislators so they don't pass laws that hurt small hospitals, he says.

"We're very fortunate that we've got a considerable sum in the bank and have been well-run for many years," Harris says. "But I could see that just a few bad years could change all that."

Grande Ronde, situated in a town of 12,000 people and the only hospital in Union County, Ore., also has connections with a bigger hospital in Boise, St. Alphonsus Regional Medical Center.

The trend toward coordinating care through alliances among providers can be particularly challenging for small hospitals in rural areas, which have fewer choices for partnering up. "When you start talking [accountable care organizations], the crystal ball gets murky," Harris says. "We're still not sure where this is all going."

In rural southern Maryland where Stewart lives, the challenge for Calvert Memorial is staying independent and providing care to the local community while surrounded by larger health systems. Prince Frederick is about 45 minutes from Washington, D.C., and 90 minutes from Baltimore. It is a bedroom community, many of whose residents work in the bigger cities and commute.

"We are the sole provider in our county and on our peninsula," Stewart explains. Calvert Memorial has 106 beds. "We're surrounded by hospitals owned by systems. But we're a freestanding, independent hospital and we want to stay that way."

Like many other small hospitals, Calvert taps expertise from bigger partner hospitals such as Johns Hopkins.

Calvert has a particular focus on patient safety and quality, and the board tries to spend about 25 percent of each meeting focused on those issues. It's what drew Stewart to become a hospital trustee when he moved to Calvert County from suburban Washington, D.C., about 20 years ago. "I'm proud to be part of a hospital that has a staff that cares about safety, about quality of care and patient satisfaction," he says. "We do things that don't necessarily add to the bottom line … they take from the bottom line. But we're trying to take care of our community."

Harris has similarly strong feelings about Grande Ronde. "It's always been a beacon of quality for those of us in the medical community," he says. "When I was asked to be on the board I felt honored and just enjoy being part of a wonderful organization."

Even with a background in medicine, Harris had the typical experience of the new trustee, working his way up the steep learning curve of hospital finance and reimbursement. "These issues are horribly complex and there is sophisticated financing," he says.

Because hospitals depend so much on public health programs, it's vital that board members understand what's happening in their state capitals and in Washington, D.C., on health policy, Harris says. "None of the small rural hospitals have a huge operating margin," he notes. "The money and policy coming out of Washington is very important to us."

When Hinson ran for a spot on the public district board for Weiser Memorial, she already had experience in policy. She had worked with federal agencies on issues regarding her family's livestock operation and also had been a state committeewoman and was active with sheep industry organizations. But she also had to learn the ins and outs of hospital reimbursement and health policy.

"Politically I was fine," she recalls about her first days as a hospital trustee. "I understood board functions and governance. But health care is a whole different animal from your typical business."

She also stepped into the role just as Weiser was deciding whether to seek critical access hospital status for the hospital. "Everybody agreed it was the right way to go," she says. "But there definitely was debate about the hospital's future, how we would sustain it. That debate continues as we look at all the changes going on in health care."

Speaking for the Community

All three Grassroots Champions believed strongly in their small hospitals and their roles as both providers of quality care and economic engines in their rural areas. The next step — to advocate for their organizations — was natural. "If you really believe in what you do for a hospital, you need to make sure it's done in the right way, and to let the legislature know what your community hospital does for the community," Stewart says.

They all worked with their state hospital associations to learn how to meet with legislators and their staffs, either in general meetings to educate them about the issues facing small hospitals, or to lobby on a particular issue.

For some, the idea of stepping into the role of advocate was a little daunting. "I found it quite intimidating, just the level of knowledge you need to talk with these people," Harris says. "But I found as time passed I would become more verbal and feel I had a fairly good understanding of what's happening."

Coyle of the Maryland Hospital Association says that response is common. "Some trustees approach the task with some trepidation," she says. "But there are no better spokespeople for our hospitals than the volunteer trustee leaders who guide them."

Knowing the issues can help a new advocate feel confident walking in the door, the trustees say. They're taking what they've learned about health care in the board room to educate public decision-makers.

"Health care is so complicated it's really difficult for someone outside the field to get their arms around it," says Hinson. "So we've been educating people about the issues so they have a good, basic understanding of what the Medicaid funds provide and how critical they are."

That message is not just about the patients who benefit from Medicaid coverage and the hospitals for whom the program is a major payer. It's also about the dollars coming into small communities that support their economies. "Medicaid spending maintains jobs and the local economy," Hinson tells lawmakers.

She recommends doing your homework before entering a meeting. "The first lesson is to be very well informed, know what you're talking about," she says.

Trustees bring both information and a unique credibility with them because of their status as community volunteers and their knowledge of their communities. Often they may have connections with legislators from other community or professional activities. "There's been a greater recognition over the past three or four years within the Idaho Hospital Association that trustees are pretty valuable at the legislative level," Hinson says. "They've been within the communities for a long time, they know their representatives in the Idaho legislature and they know the congressional delegation pretty well, too."

Toni Lawson, vice president for government relations with the state association, confirms that Hinson's history at the state level is invaluable. "Margaret has a long history in Idaho and is widely respected because of her role in health care, but also because of her expertise in natural resources, agriculture and ranching," Lawson says. "Whenever needed, she is willing to make important calls to key legislators or members of Congress and add to the larger advocacy agenda by focusing on her rural hospital."

That's why it's helpful to impart not just the facts about what their hospitals need from public policymakers, but also personal stories that illustrate the point. "Always relate it back to your community and what it means to people," Hinson suggests.

That technique came in handy for Grande Ronde Hospital a few years ago when representatives were talking with the congressional delegation about a proposal to relax the 25-bed limit for critical access hospitals, so they can have some flexibility to accept a few extra patients when there is high demand (the proposal has been included in several bills, but has not been successful). "The first time we had to turn someone away because of the 25-bed limit, it was an elderly person and we had to fly the patient to another hospital," explains Wendy Roberts, senior director of administrative services. "We were able to share that story because it was something that impacted us."

It's also good to make it a two-way conversation. "You really learn more about where they're coming from by listening and noticing what questions they're asking of you, rather than just espousing something," notes Hinson, who also is now serving as the first female president of the American Sheep Industry Association.

'Different Perspective'

The board role in advocacy is unique. "Trustees bring a little bit of a different perspective," Hinson says. "They're invested in the community long term, and it's a little different from being employed by the facility."

Harris agrees. "Representatives look at the CEO as someone with a vested interest," he says. "But they look at the board member as someone who is more of a constituent. We have their ear."

Harris urges trustees to make visits to their representatives, particularly if they are already in Washington, D.C., for an AHA meeting. "Small, rural hospitals would be easily overlooked without good advocacy by trustees and board chairs. Without good, responsible legislation, small hospitals could go away."

Jan Greene is a freelance writer in Alameda, Calif.

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