Hillsdale Hospital News

Episode 91: Elder Care in Rural America

Rural communities often have a larger proportion of elderly residence compared to their urban and suburban counterparts, contributing to a larger proportion of elderly patients receiving care in rural hospitals. They are also less likely to have access to support at home, adequate resources , and other factors to take care of themselves after they leave. To help us further understand the issues of elder care in rural America, we welcome this week Dr. Ali Shukr, Director of Hospitalist Medicine here at Hillsdale Hospital.


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Audio Engineering & Original Music by Kenji Ulmer




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Rachel: Rural communities often have a larger proportion of elderly residents than their urban and suburban counterparts, contributing to the larger proportion of elderly patients receiving care in rural hospitals. They are also less likely to have access to support at home, adequate resources, and other factors to take care of themselves after they leave. So how do rural hospitals provide excellent elder care that overcomes the challenges and meets the needs of its vulnerable patients?

JJ: With a passion for their patients, a willingness to dig deeper, and an unrelenting determination?

Rachel: I’m Rachel Lott.

JJ: And I’m JJ Hodshire

Rachel: And this is Rural Health rising.

JJ: Welcome to episode 91 of Rural Health Rising. I’m JJ Hodshire, president and chief executive Officer of Hillsdale Hospital.

Rachel: And I’m Rachel Lott, chief communications officer.

JJ: Rachel, today we have a return guest, one of my best friends in all the whole wide world. He’s been on this show with us in the past a couple of times now. He’s passionate about his work here in rural Hillsdale, Michigan, and he has a special interest in the elderly patients we care for.

Rachel: That’s right. We are talking with someone who is committed to our patients and our community and who always goes above and beyond in caring for our most vulnerable patients.

JJ: Our guest today is Dr. Ali Shukr, director of hospitalist medicine at Hillsdale Hospital. Welcome once again to Rural Health Rising Dr. Shukr.

Dr. Shukr: Thank you. Thank you for having me to start.

Rachel: Dr. Shukr, some of our listeners have met you before, but some might be new. So why don’t you give everyone a refresher and tell us a little bit about yourself, your background, and your work here at Hillsdale Hospital.

Dr. Shukr: Well, where do I begin?

JJ: When you were a small child?

Dr. Shukr: Actually, this has become my home over the years. Made a lot of friends, family, brothers.

JJ: That’s right.

Dr. Shukr: My background is internal medicine. I’ve been here since 2016, right at a residency. I found a second home here. And, you know, I practice hospitals medicine. Been doing it. I’ve got promoted to medical director.

JJ: That’s right.

Dr. Shukr: Back in 2019. Have a strong team behind me. Not just on the floor, but in the background. The C suite. Let it spearheaded by JJ himself.

JJ: So, Dr. Shukr with your background, residency was where?

Dr. Shukr: Residency was in St. Joe’s.

JJ: That’s here in Michigan.

Dr. Shukr: You’re in Michigan.

JJ: Yeah, correct. And what I mean, what drew you to hospitalist medicine? Because you’re brilliant. You could go start your own practice. You probably make millions of dollars. And you’re from the Metro Detroit area, generally speaking, and you’re down here in Hillsdale, Michigan, which population in the county of $47,000. It’s quite the transition. So, talk to us a little bit about what you studied in med school that intrigued you about hospitalist-based medicine and really what drew you to Hillsdale?

Dr. Shukr: Well, this is kind of a I don’t know if I’ll make it a long version, please. A short version first I’ve always been interested in medicine since high school. I think I’ve mentioned this before. When I went to college, I knew what I wanted to do when I went to residency. When it came to choose residency, one of my favorite shows on TV.

JJ: Let me guess. General medicine?

Dr. Shukr: General Hospital. How? That number was okay so far. Medical dramas was House.

JJ: Oh, yeah.

Dr. Shukr: House MD.

JJ: Right. I forgot. You’re young. Okay.

Dr. Shukr: All right.

JJ: I would say Quincy, MD. But you don’t remember anything.

Dr. Shukr: That was a movie, but that inspired you. It does, because that show brought up like, a lot of facets of medicine that intrigued me, especially the mystery of it. Mostly. It’s almost like the Sherlock Homes of medicine when it comes to internal medicine, is to figure out what’s wrong with someone. If you’ve watched the show or if you are in medicine, you know you have a puzzle, you have a problem, and you have a lot of tools at your disposal to solve. When I trained, I trained a large hospital, so obviously I had a lot of tools at my disposal. So, the puzzles were easy. They’re like almost like a 100-piece puzzle.

JJ: And resources were unlimited, or unlimited resources.

Dr. Shukr: Unlimited. Not just within the hospital, but within the surrounding hospital.

JJ: Correct.

Dr. Shukr: But when I came to Hillsdale, I’m more of someone that likes the hard puzzles, the ones they have to fix upside down type. Not that I ever have.

JJ: Well, that’s here at Hillsdale, though, for your patient population. High acuity.

Dr. Shukr: High acuity.

JJ: Very sick. Many of them not receiving medical care.

Dr. Shukr: Timely or annually, initially, prior to me. So, when I did start, specialty services were not as abundant as you find other areas. So, figuring out issues and problems took a lot more. The complexity just kind of went up higher. That intrigues me.

JJ: That’s kind of your sweet spot, isn’t it?

Dr. Shukr: Why I get up in the morning?

JJ: We’re going to talk about that in a minute. But I want to ask you, hospitalist medicine, someone who may be listening to this goes, what is that? Could you explain the model? And were you here when we transitioned, or did you come after we’d already made the transition?

Dr. Shukr: I came, I think, two and a.

JJ: Half years after the transition. So, talk to us about what a hospitalist is, what you do and why they’re important.

Dr. Shukr: So, hospitals, medicines, usually they’re physicians and providers trained in either family medicine or internal medicine. I myself, being internal medicine, we are the primary care within the hospital.

JJ: Right.

Dr. Shukr: Previous model to, I guess, the medical system in America was if a patient was admitted to doctor so and so when he was admitted to the hospital, their doctor that they see in the outpatient setting will round on him in the hospital. That left room for the doctors. Rushing through examinations or seeing patients late led to prolonged hospitalization stays. The model came up. Why don’t we just have a physician dedicated in the hospital just to care for hospitalized patients. I e. Hospitalist Medicine so we treat and diagnose and manage multifaceted patients from all disciplinaries. So, we’re like the quarterbacks when it comes to the hospital of directing care throughout the hospital for the patient.

JJ: Right. Coordinating that care. In many cases in rural communities, you serve as a pulmonologist infectious disease. There is that responsibility. Now, we’re blessed because here we have a pretty robust continuum of care. But in rural communities, you really don’t see a lot of what we’re able to offer.

Dr. Shukr: Not at all. I mean, in some communities, they don’t even have a hospitalist floors. They stay in the Er as a freestanding Er. Tell that to someone that’s not in America, that this happens in America, they’d be quite surprised. When everybody thinks about medicine, American medicine, they think it’s state of the art talk.

JJ: Glamorized and all have every TV drama.

Dr. Shukr: There’s a certain expectation, but in reality, that’s not always the case.

JJ: Yeah, absolutely. So, hospitalist the guy solving the puzzle. That’s a little bit about your profession. But what I want to know we’ve asked you this question before, and we always start with a why. And I really want to know, as a person, what motivates you? What gets you up out of bed in the morning to cause you to do the things that you do? Now, I want to put a side note here. Sure. The types of things that you do are beyond medicine. And the fact that two summers ago, without anybody knowing, you go down to the local basketball court and you replace the hoops in the nets and you jump up on your beautiful Cadillac Escalade, which I would have never have done, but anyway, I would have got a ladder and you put in the nuts. And for a poor community, that means a lot. So, I know the types of things that you do. You even visit our patients when you’re not working, if they’re transferred. But I want to know what causes that to stir in your heart, what motivates you to do those things.

Dr. Shukr: I don’t want to sound like a cliche, but it’s really to make a difference, not necessarily in medicine, but to make an impact on someone’s life. Because growing up, I’ve had a lot of people make an impact on my life that I remember by. I always want to be that to someone else. Not necessarily through medicine, but through anything. Anything that I do. Life in general. That way, when people say they’re mentioned or mention my name, it’s mentioned in good standing. What do we leave behind this world when we’re gone? We leave our name and our legacy. It’s true. What do you do with all your talents and all your things that are handed to or made in this life is kind of what you’re judged by. Not that I care what I judge, but I want to be seen as someone that’s a positive impact, not just to my community but to everybody around me.

JJ: Well, you certainly are. And your impact here at Hillsdale Hospital and your contribution has allowed you to serve as a medical director where you do a great job providing twenty-four, seven care to our patients and directing that care. Obviously, you don’t provide it yourself 24 hours a day, but you do provide it probably 18 hours a day. And when you’re here, you’re on point at seven days. It’s very intense. And you’re also assisting us in the emergency department where you can and you’re also going on to a skilled nursing facility and you’re responding to codes and it’s a significant amount of work. But let’s segue into something very specific. We serve an elderly population in this community and I want you to talk to me a little bit about what role the hospitals play in giving care to elderly patients. And from your perspective, what is that experience like?

Dr. Shukr: Well, this actually subject is pretty broad to me. Meaning, as I mentioned, I’ve trained in a tertiary facility in residency. It didn’t really impact me until I got out here to realize elder care, that our elderly population, how underserved they are, especially in the rule settings, for many different reasons and many known reasons. Some factors are just logistically, financially versus just where they’re at in life. And it was very apparent to me just from the get go that the elder population in rural medicine are much sicker than you would see in urban or community hospitals of larger cities.

JJ: Let’s talk about that. Why is it?

Dr. Shukr: Well, there’s a lot of disparities why it is. One would be a lot of other live in rural communities, whether it be because of retirement or chosen lifestyle later down in life, are the kids, you know, that they left the nest yeah. To go to other city, to larger cities for more job opportunities behind mom and dad by themselves. Now grandpa, grand grandpa or great grand grandpa. I mean, I’ve seen a lot of Centennials, a lot of patients of older age, I’ve seen quite a few in the hundreds here in this area. They live a lot longer. They’re not dealing with the due stress of city life. Not at all, not at all. But they do definitely have their own problems. They are very unique. The Lavin rural communities tend to be more below the poverty line than the lady of the same age in the cities. They don’t have the resources or access to the resources that they would if they were to live in large cities. And they don’t have the know-how, they don’t know what things they have for them to offer. They’re very isolated, secluded, and they tend to do poor when it comes to their medical health. And it’s very apparent to me the elderly population here in this area are a lot sicker with a lot more chronic condition. I know we’re going to probably talk about this later. I feel where this conversation is going, and it’s a conversation I’ve always wanted to have. And I usually have a lot of these conversations with family members or even patients themselves that come to the hospital when I propose certain things for them and asking them how to better their environment, better overall health that they knew not of.

JJ: Right. And I think the challenge also when you look at rural communities, we talk about poverty, access to prescription. That is a significant concern for elderly population. In many cases, they are making decisions between paying the light bill and paying for the Copay on the Meds or Med on a vital Med. We know for a fact, and I’ve intervened in several cases personally, where individuals couldn’t afford their insulin costs. And you go without your insulin. That’s a game changer. That’s a game over at certain points. And we’ve witnessed those people present in the emergency department. The other issue. So, medication disparity the ability to purchase those Meds, which we take for granted when we have good jobs. It’s good health insurance. The other issue is transportation. Right?

Dr. Shukr: That’s huge.

JJ: And the lack of transportation is number one in our community. We have a public transportation in the city only dial ride, business hours, no weekends. No weekends. Not bringing in from Camden, Waldron, and those communities. We see that in a lot of rural communities, lack of transportation. So truly, they’re home bound. They have no vehicles or they can’t drive isolated. So, depression, untreated, can’t get your Meds. And as a result of that, you have poor healthcare outcomes.

Dr. Shukr: They can’t get to the physician appointments, follow appointments to check up on their kind of keep their kind of conditions in check. Everything spirals downhill, and a lot of them meet an untimely.

JJ: They do. In how many cases, when you’ve been practicing medicine here, would you hear that story? Like Dr. Sugar. We couldn’t get in. We didn’t have a car. I want a sense of this country because this is a national podcast to hear what we’re facing in rural communities. How many of those cases are you hearing?

Dr. Shukr: There’s a great majority of those cases. It’s astronomical. The numbers and the spirit of how much I hear about it. It’s almost every case. There’s some sort of issue within the elderly care that may, if corrected, may have not let them up to be hospitalized or taken a worse turn in overall health. So, I kind of always want to educate, bring awareness that, yes, we live in trying times, but we’re doing things differently now and providing more for this self-population in order to stop that from happening, to put a halt to help ease the burden of aging.

JJ: Yeah, absolutely.

Dr. Shukr: Nobody ages gracefully.

JJ: No, it’s rare that they do it.

Dr. Shukr: It’s a blessing.

JJ: And especially if you’re in poverty, aging can be very hard on you not having access to vitamins and having access to your scripts, but not just hard.

Dr. Shukr: On the patient themselves. Hard on their families.

JJ: Oh, family who may have moved away and they cannot get home to mom and dad or grandpa or the living.

Dr. Shukr: The grandma and grandpa. They can’t themselves and they can’t take care of them anymore.

JJ: Correct. Because they themselves may have conditions, chronic conditions.

Dr. Shukr: So, it’s a spiral effect. It’s a vicious cycle.

JJ: It is.

Dr. Shukr: So here at Hillsdale Hospital, we want to bring awareness to try to help alleviate and guide better care for the elderly here in the population we serve.

JJ: Yeah, we’re going to talk about that in just a minute. And I know that Rachel has a question that she wants to ask before we jump into too much of that.

Rachel: What types of conditions do you typically see in your elderly patients?

Rachel: How much of the complexity is due to unmanaged chronic conditions versus really severe acute conditions? Maybe that come up and are just more difficult because of the patient’s age.

Dr. Shukr: Well, what type of conditions? We see the hospitalized conditions for your typical heart failure, diabetes, kidney issues, pulmonary issues, infectious issues, orthopedic issues, a lot of fractures, hip fractures, and elderly populations. And then even with those conditions themselves, you can bring that further. When it comes to diabetes, you have the complications of diabetes, of coronary art disease, hypertension, heart issues themselves. When they tend to present with these cases, they’ve come with multiple, I like to call flare of these conditions at the same time. Second part of your question, it’s not just one.

JJ: What amazes me is when you tell me a story of a patient who will present and it’s five issues that you’re dealing with. They’ve not addressed the abscess, tooth. They have feet or swelling, legs or swelling, and then they’re in for COVID or they’re in for something unrelated to even some of those diagnosis. Right?

Dr. Shukr: Yeah.

JJ: And now you’re managing complex cases. And guess what the government tells us? What was their initial admission? Right.

Dr. Shukr: Toothache. Yeah. Too big.

JJ: And the government says, all right, you have X amount of time as a.

Dr. Shukr: Physician, you cannot ignore the other issues at the same time.

JJ: No, you have to you have to.

Dr. Shukr: Do right by the patient all the time, because this may be the only opportunity. They’re going to see a provider for God knows how long, and other conditions are going to spiral a lot of if left unchecked.

JJ: Absolutely.

Dr. Shukr: So, as a hospital’s medicine, this small.

JJ: Window to capture them and to get them healthy to the extent that and.

Dr. Shukr: Educate them of the services that are available to them that they would have never knew otherwise had they not come up.

JJ: We’re going to talk about that in a minute, but let me ask you one more question. As a follow up to this depression in seniors, are you seeing an increase in this. There’s obviously seasonal depression. But the population that you’re working with, the elderly, let’s just focus on them. What do you see as it relates to depression in the elderly?

Dr. Shukr: There is a big uptick in depression, and I say that with lightly because when it comes to elderly, when you talk about depression, the together depression and dementia, some people mistaken dementia for depression and vice versa. A lot of the elderly are living alone nowadays. There has been a lot of changes, especially with the elderly’s financial situation that leads to depression. A lot of elderly couples have lost their spouse. When it came to COVID, there was a large disparity of COVID deaths amongst the elderly leaving, and they’re all sudden leaving. The other spouse left with depression coping skills, very difficult.

JJ: Or the spouse dies and they take the only income, which is Social Security.

Dr. Shukr: Yes, in the family as well. But then again, depression usually goes untreated and unnoticed in the elderly population because a lot of people mistaken it or just throw it off as part of getting old.

JJ: Yeah, it’s part of aging.

Dr. Shukr: Right.

JJ: They’re withdrawing, they’re sleeping a lot, they’re naturally going to sleep a lot. But that’s concerning. They’re not eating right, they’re scaling back on food, they’re sleeping more. But those are all symptoms and signs of depression.

Dr. Shukr: Yes, and they’re not going to bingo night because they can’t walk. So, they lose interest in the things they normally would do.

JJ: And they’re justified because they’re just getting older.

Dr. Shukr: It’s hard for them to walk.

JJ: In contrast, my wife’s grandfather, so on her side, is 95 maybe and drives and he’s out and about. And so you can’t use the mentality and framework of saying that, well, they’re just getting old, they’re just giving up. In many cases, that’s where we see depression linked up. And then it can have, obviously, psychological impact, but it also can lead them to some physical impact as well.

Dr. Shukr: Because when someone’s depressed, you think they have lack of motivation for self-care, to go to their appointments, to get their medications filled, to eat, to take their medications. And in turns, their conditions start getting worse.

JJ: They worsen.

Dr. Shukr: And then this all could have been avoided.

JJ: You mentioned something earlier, you said that patients that live alone all right, let’s talk a little bit about that because that’s a real threat in my mind to our elderly patients is that they are living alone and with little or no care. And especially in rural communities where it’s very difficult to get those services. In rural communities, even meals on Wheels, very difficult, which big cities they boast of being able to deliver food. You can call it grub hub. Yeah, right. That doesn’t exist in hills, so there’s no grub hub. And so, for the patients that you see that live alone, let’s talk about them primarily. With no family around, you’ve probably had to dance around some of these issues in your past. And I guess my question to you is, how is your care plan different for a patient who let’s just take an example. They’re in their 80s. They live alone. Family lives in California, right? She’s widowed and she has some comorbid conditions. You notice some things aren’t just right. How do you manage that with a family in California when it comes to making decisions for their care? Let’s focus on that.

Dr. Shukr: You pretty much just described the majority of patients that other patients we see because they fit in that same category. They don’t have family around. So, when a patient comes in the hospital, obviously I want to see where the mental is. Usually, they have some mental deficiencies. It could be because the condition they currently have. But I always want to have family involved in their care. I always ask which family members don’t want to get involved. Some patients have multitude family members that.

JJ: Are involved and some a lot involved.

Dr. Shukr: Some are involved with different opinions, with.

JJ: All different opinions to work with you on some of those.

Dr. Shukr: Yes.

JJ: But let’s say the elderly patient that has no family or that live in California, how are you managing that?

Dr. Shukr: So, I call California because I have to do what’s right with the patient. I approach as if I’m treating my own grandmother or grandfather.

JJ: Yes, which I appreciate.

Dr. Shukr: I would want the doctor to call me, hey, Grandma’s in the hospital. I haven’t seen my grandma in months, right. And I get a call, Doctor, tell me in the hospital. But then again, I’m asking them questions that they probably wouldn’t know because they.

JJ: Don’t know what their baseline is.

Dr. Shukr: Right, exactly. That’s challenging for a physician. I’m trying to treat something that may not be reversible, as if actually delirium. Is this dementia or is this depression? Because delirium is most likely reversible. So, I’m trying to treat someone not knowing where the end line would be. Now, could this patient be no longer able to care for herself? I can’t send her home anymore, right? It’s not safe for her. No one can take her. She doesn’t fall risk; she doesn’t take her medicines. Now we have to place this patient.

JJ: And this is the stuff let’s preface this before you start talking about that. Sure. This is the stuff that is heavy on our minds as administrators and as care professionals, because this is the stuff that you don’t see on TV. This isn’t the glamorous stuff. These are the tough decisions we have to make, which includes and not limited to even getting the courts involved.

Dr. Shukr: Yeah.

JJ: So, let’s talk a little bit about that scenario. Carry it out for us.

Dr. Shukr: So once the patient is deemed medically stable, which doesn’t take too long, we do a battery of tests to ensure medical stability. But once you get medical stability and they’re not mentally stable and they’re not cognitively there, they’re deemed incapable of making medical decisions. Now we’re going to find out who’s going to make medical decisions for them. Because going forward, any paper or legal document signed, rendering treatment, not rendering treatment, discharge has to be signed by competent individual patients. Not competent. Now we have a whole different issue on our hand.

JJ: Correct.

Dr. Shukr: Is it going to be the courts? Is it going to be family members? Is there someone that’s our living will is there a dual power of attorney? Is there medical appointed medical personnel?

JJ: Yeah. In many of these cases, there’s no POA, there’s no durable power of attorney. There’s no medical power of attorney.

Dr. Shukr: So, they teach us in med school and residency to do what’s best interests of the patient, but doesn’t allow me to send anyone where I want to send them. So, we have to wait at times, we have to wait for a court reporting guardian, a court appointed guardianship. At times there’s family members that would step up that are in the best interest of the patient. But then we look for facilities, long term care facilities. But then you run into the I’ve run into many issues where the patient cannot go home. Family members cannot take them to their home. However, they are the medical power of attorney. Patient has stated they do not want to be placed in a nursing home at all. And we’re stuck in you’re stuck in the middle. Stuck in the middle. So, what do we do? There’s no other choice. There’s this big stigma about nursing homes. I’m not saying I want to stick mom at a nursing home. I don’t want to take care of her, but mom can’t take care of herself. But being inside the hospital, living inside a hospital is not the answer either.

JJ: Right.

Dr. Shukr: What do we do?

JJ: Right.

Dr. Shukr: So, we face these issues all the time, multiple times a week.

JJ: Numerous. Too numerous to even count at times.

Dr. Shukr: And then at the end of it, it’s the patient that’s sitting there waiting for anyone to make a decision for her or for him. And my heart always goes out for him because I know they’re going to be placed in their home. They’re going to live out the rest of their life not at their home.

JJ: Right.

Dr. Shukr: Which would not be the safe place. Which might be it should have been there years prior.

JJ: Absolutely.

Dr. Shukr: When I have elderly patients that come that I normally see that are cognitive intact, they’re still lucid, they still make decision. I would take a few minutes to talk to them about if they’ve had these tough conversations with their loved ones. Do they have a living will? Have they appointed a durable medical power attorney to do so? So, you don’t put other family members in the middle, make these decisions for you. Lay these out. Because having these tough conversations when you can save a whole lot of time and money for the patient’s, patient’s family later.

JJ: What’s really troubling to me and I’ve been doing this now for almost 14 years in health care. And it’s the number of patients, typically elderly, that we see in which the family refuses. They don’t even return our calls to get involved. We’ve had those. We then have to go to the courts.

Dr. Shukr: Yeah, they drop them off in the Er and that’s it. Audio still, they’re done. They don’t leave a callback number.

JJ: When I share that story, Doctor Sugar, people don’t know that. No, this is what we deal with. It happens all day and we don’t call it stuck with the patient. But the patient is placed here and we now have to petition the courts. Sometimes taking weeks to be able we’ve had months before.

Dr. Shukr: Months before. Patient has been several holidays with us.

JJ: Yes.

Dr. Shukr: Medically stable.

JJ: Correct.

Dr. Shukr: But nowhere to go.

JJ: Nowhere to go.

Dr. Shukr: And no one will take her.

JJ: No one will. And family goes, no, we can’t take mom in. We can’t do this. And we have to get the courts involved. And that’s what we find as a significant concern to wellness of these patients. Yeah, being here in our bed is not the appropriate place for them.

Dr. Shukr: But some of these cases, well, mostly cases, I always like to look at perspective, patients’ perspective, family’s perspective sometimes these patients, yes, true, they are sick and they are complex and their medical needs outweigh whatever family member they can give at home. And it’s not they’re dropping off in the hospital and abandoning them. They knew the hospital or the health system will treat them better than they would do at home. And it’s sad.

JJ: It is because there’s limited resources.

Dr. Shukr: Limited resources, caregiver fatigue. Some of the caregivers that are don’t know, 24/7 are not properly given the appropriate care. No. For the loved one.

JJ: Absolutely.

Dr. Shukr: Although and their intention is right.

JJ: But their intention is to give good care. But you know what? They’re limited. Right? They may not have the funding. They may not have transportation themselves. And this is what the pandemic intensified.

Dr. Shukr: This the pandemic not just the inflation, because the caregivers they’ll pick up, the Medicaid. I’ve heard a lot of time where their elderly medication prices went up and the person responsible for picking it up don’t have, they don’t have the resources. They’re copay. They used to. But we hear that medical plans change. They can’t afford it.

JJ: Jobs, loss of income, so they don’t.

Dr. Shukr: Give them the proper care. It’s almost on the borderline of neglect where, you know, they need this, but you’re not giving it to them for X amount of reasons.

JJ: We had an elderly pastor in our community that came in a few months ago and he shared his story with me that he stopped taking a certain medication that was costing $1,000 a month and he really needed this medication. And in service to God, you don’t get paid a lot in small rural communities. Being a pastor. I mean, it’s a few. Hundred dollars at times in churches that are struggling with small congregations, don’t have big giving. And anyway, it’s a reality that we face in rural America of the challenges of our elderly population that do not have access to families, transportation, suffering, depression alone, and all of these things, they boil up and they create a very.

Dr. Shukr: Bad situation for the whole system at large. There are times, many times where I find that to be true, where patients are in the hospitalized for not taking their water pill. They’re in here for overload or whatever reason. They’re not taking a pill for financial reasons, knowing that their drug plan changed. The drug that they used to take that the doctor keeps writing for them, they can’t take because they can’t afford it. But you look for an equivalent medication that’s cheaper, but they didn’t know that their doctor could have written for that it would have been able to take. They don’t have these, and they’re not able to go to physicians to have these conversations. Again, transportation wise, lack of resources. So, there’s a lot of things that the elderly population just do not know.

JJ: Yes, absolutely.

Rachel: Of course, specialty care is important for many of your patients. And we do have quite a variety of specialty care, either on site or remote, that we can access at Hillsdale Hospital. But it hasn’t always been that way. So how did you manage before? We had as much specialty care as we do now. And how has the addition of those specialists impacted your care and your patients?

Dr. Shukr: Yeah, so in the last few, last few years, we’ve actually made a lot of positive changes there. He’ll at the hospital, which I’m very proud of and spearheaded by JJ himself.

JJ: Thank you, doctor.

Dr. Shukr: Sharon.

JJ: No, I couldn’t do without you and the team that we have.

Dr. Shukr: Absolutely team effort. But for specialty care and medicine, it’s known elderly care lack ability to see a specialist in rural medicine because as a specialist, they don’t practice normally in rural medicine because there’s not the patient population for them. There’s not enough of the patient population in order to build a specialty practice, for instance, nephrology, vascular surgery, et cetera. But that doesn’t mean it’s not needed in the health care center. So, in the beginning, when I first started, I did not have these services, but I was reaching out to many colleagues in the area, reaching out for other resources, sometimes even transferring patients to see these specialists because they needed them. Then over time, it was just over three years, I realized these services will flourish in rural communities with the change of technology we’re like, we can offer these, and then programs start to build. And one thing came out of the pandemic was when everything went tele. Then these tele services were brought in to fill the need. And now, three, four or five years ago, when there was no access to nephrology here, now we have access. We’ve created a need. Sorry, we did not create we proved that there was a need, right. And we brought that need and filled.

JJ: It, which is critically important in rural America that you don’t have patients, again, without transportation, who can’t travel to specialty care, bringing in the services that we’ve been able to bring here, patient taking care of in their local community, I think that is just so important and powerful. So, let’s talk a little bit about and our time is really escaping us. And there’s one more question I want to ask you, and it’s relative to the discharge process of a patient. And many times, you’re functioning as a social worker, a pastor, a family member, a friend, a mentor, a financial advisor, taking them home, even following up on them. So, when it comes to the discharge of elderly patients without a lot of resources at home, whether it’s home care, meals on wheels, what does that process look like for you when you walk in that room, you see that 85-year-old widowed lady laying in the bed getting ready to be discharged. You’ve talked to her son in California. Your heart’s breaking because you’re trying to, number one, even get her a ride home, right? Talk to us about how that looks in rural healthcare, and then I’m going to challenge it. I’m going to ask you; how can we change that? But tell us what it looks like right now.

Dr. Shukr: So, what it looks like now. Challenging an elderly patient for me is one of the challenging parts of my job because it takes up a lot of my time because I incorporate a lot of disciplinaries in order to do so. It’s not just, okay, you’re medically stable. Go home, assign the paper, do your discharge, and we’re done with it. When I go in the room telling all the patients you’re going home, they light up like a Christmas tree. But I tell them it doesn’t take me a few hours because there’s a lot of things, I have to keep make sure are aligned in order to do so. For instance, I get a lot of services involved, such as case management, charge planner, our social worker, our dietician, our physical and occupational therapist. They all have to check off to make sure that the services that we can offer are delivered to the patient in a timely fashion. I make sure I call. If they’re elderly and they have children, I would hope they appreciate me calling them that. I know how mom and dad did what next steps are just so I’m sure that they’ll follow up like, hey, mom needs to see a cardiologist next week. Make sure you follow up on an appointment because elderly patient, you can always trust that they’re going to remember. You can write in a discharge paper, but you can’t always trust that they’re going to look at that paper, kind of give the overview for another family member of what’s going on. Just so everyone’s on the same page and can remind the patient. Also, always have pharmacy involved to look over the medications. Once again, if there’s any interactions with certain medications because as you age there are certain medications that Lee should stay away from. Just because you’ve been taking for 30 years doesn’t mean you should be taking it at your age now because now, they’re more prone to side effects. And then some of the things that I take into consideration is if they have food at home, if they got to take medication, food was the last time they went grocery shopping. Do they have the proper here in our area? I always ask about their heating in rural medicine. So, everybody is privy to natural gas heating. A lot of people use wood burning stoves. If they do ask, if they have certain questions that I ask do they have enough wood for the wood lesson during the cold spell? Who checks up on them? How are they going to get to the next appointment?

JJ: So, when they tell you that they can’t get to the next appointment, what do you do?

Dr. Shukr: We try to reach out to see if I can get them placed in rehab facility or assisted living facility. If they meet criteria for, I try to give them all resources that they may benefit and have that they didn’t know. Try to explore all avenues, but ultimately sometimes that doesn’t always work for us. Patient ultimately goes back home and two or three weeks later we’re back to square one again. And it’s not like we failed in the first time. It’s just the way our system is made or it is designed for them. This is one thing that needs to be looked at further.

JJ: If there’s one thing that you wish you had a magic wand that you could wave as it relates to our elderly patients in terms of this social situation, what would it be? When you think about what you’re discharging right now, the number of patients that are going home, is it resources? Is it family? What is the number one that if you could impact and empower and change this particular very serious situation, what area would it be?

Dr. Shukr: The number one, it’s going to be resources. And then I have to follow that up with number two is mental state. As people get older, it’s okay to go live somewhere, even with your family. You don’t need to live in a 3000 square foot farmhouse. You’ve been living there for the last 60 years. It’s not conducive, it’s not safe to do so by yourself. It’s going to be more harm. Yes, that’s what you want. But is it the right thing to do? You’re isolating yourself from everyone. And lastly, it’s literally, literally for Medicare to be more fluid in this economy, to be more adaptive.

JJ: We didn’t rehearse this.

Dr. Shukr: No.

JJ: So, it’s not like you’re spot on.

Dr. Shukr: Because it hurts me when I see patients that worked all their lives on retirement. They solely rely on Social Security. They can’t afford a meal or a simple medication. Yeah, it’s like they went through all their lives, busted their behind, but they can’t afford a medication. They don’t know where their next meal is coming from.

JJ: Yeah, it’s a daunting, and it’s very.

Dr. Shukr: Daunting, and it’s getting worse.

JJ: The challenge has never been as real as it is today. Dr. Shook her to empower families to check in on their loved ones, their elderly loved ones, their parents, their grandparents, and to really understand that they could be the bridge to making sure that mom, dad, graham. Graham could live another four to five years. If these things are detected early, what we know is early detection is early prevention, and if we can detect something in this population early on, it’s not going to be as costly down the road. It won’t result in them having to have rehab down the road, potentially. It’s really putting your eyes as a family member on your loved one. And I think that is so important. We have neglected and thought that, well, it’s mom’s responsibility to take care of grand, grandpa, why isn’t it yours? Yeah.

Dr. Shukr: So, I mentioned this to a group of colleagues one day. We’ve had these conversations because when we talk about the cases, I’ve got an elderly place one time, come in the cool cases or whatnot, but one of the initiatives I’m going to want to push for is declaring a day an elder day. We have Mother’s Day; we have Father’s Day. We have Best Friends Day. You have Grandpa Day. But I think we should have a day that’s called elderly. And that day should be dedicated to visiting an elder person in your family or friends and to see how they’re doing, to have these conversations with them, to connect to them, because we go throughout our lives not really paying attention to them in general, that elder day should be kind of constructing over. Okay, do you have your will to help them, ask them these questions, start these conversations with them? Because a lot of people would want to talk about the last days of their lives, the last hard years. Nobody looks forward. Everybody is looking for the golden years, but we’re all going that route. Hopefully we all have a smooth and fun retirement. But as with, everything comes to an end and it’s how you end it. You got to have these conversations now on how that process is going to look.

JJ: That’s right. Speaking of ending, it’s hard to believe. Dr. Shukr, the time with you has been invaluable. We appreciate your perspective. Providing medicine in rural America is difficult. This is just one segment that we’re talking about today, and we’re going to be talking about other areas, social work caseworkers, pharmacy, and things inspired by your text to Rachel and I about opportunities for episodes like this to raise awareness of these very vulnerable populations. So, once again, thank you so much for joining us today on Rural Health Rising. It’s been great to have you on the program. And before we go, we like to do a fun segment with each of our guests. We want to know what is your most unique rural experience or one of your favorite memories that is unique to rural life. Now, listen, you have been in the big city of Detroit and around those areas, and then you moved to Hillsdale, and I would say a little different than what you are accustomed to, maybe, right?

Dr. Shukr: Yes.

JJ: So, what’s unique, what was unique about that?

Dr. Shukr: Well, you asked me about my unique situation or experience I had. And it had to be in my early years when I was here, when I first encountered my first Amish patient, when I had to give him insulin to treat his diabetes. Okay, insulin, as you know, is refrigerator kept.

JJ: Yeah.

Dr. Shukr: And it was summer month, so knowing so I wrote the insulin and I asked myself, wait, it’s supposed to refrigerate, how’s that going to help? So, I had to learn really quick and ask questions for people that worked in the house for a while. How would I go about doing this? Never thought I’d ever be in this situation. I learned that there’s special parishes will give permission they do, to have an outbox or refrigerator set outside. And I had to fill out a permission slip.

JJ: Oh, yeah, the leader will allow water.

Dr. Shukr: Granted, not allow it.

JJ: So here you are trying to provide medical necessity for a population and yet ask permission if you could store the insulin in a common area refrigerator, because they obviously don’t have electricity. And did they allow it?

Dr. Shukr: Yes, they allow it.

JJ: That is a unique rural experience that most folks are not going to experience, not at all in the greater Detroit or metropolitan areas. So once again, Dr. Sugar, thanks for joining us today on Rural Health Rising.

Dr. Shukr: Thank you.

JJ: Next time on Rural Health Rising, we’ll have another great conversation with another great guest, so be sure to tune in.

Rachel: And with that, don’t forget to subscribe wherever you get your podcast. And if you like what you hear, leave us a five-star review on Apple podcasts and tell others why they should listen to your feedback helps more listeners find Rural Health Rising.

JJ: And you can now find us on Twitter. I’m @HillsdaleCEOJJ. Rachel is @RuralHealthRach and you can also follow the podcast @RuralHealthpod. Until next time, stay safe, stay healthy, and stay strong.

Rachel: Rural Health Rising is a production of Hillsdale Hospital in Hillsdale, Michigan and a proud member of the Health Podcast Network, hosted by JJ Hodshire and Rachel Lott. Audio engineering and original music by Kenji Ulmer. Special thanks to today’s guest, Dr. Ali Shukr medical director doctor of hospitalist medicine at Hillsdale Hospital. For more episodes, interviews and more information, visit rural healthrising.com.