Johnna Nynas, MD, grew up in Evansville, a small farming community of just over 500 people in West Central Minnesota. Her parents often had to decide between paying for medications or fueling up the car to get to work. Many of the area’s farming families were self-employed “so commercial insurance wasn't widely available at that time,” said Dr. Nynas, an ob-gyn at Sanford Bemidji Medical Center in Northwest Minnesota.
Today, many of her pregnant patients face similar access challenges. Four labor-and-delivery units at nearby hospitals in the region have closed over the past few years, leaving Bemidji Medical Center and its four ob-gyns to care for more than 100,000 patients.
One patient had delivered her baby at home and was suffering the effects of preeclampsia. When asked why she didn’t seek help sooner, the patient responded that she couldn’t call 911 because the only phone accessible—her cellphone—had ran out of minutes. Meanwhile, the people she lived with were intoxicated and she didn’t feel safe driving, said Dr. Nynas in a CNN interview. Situations like these drove Dr. Nynas and her colleagues to find innovative approaches to improve access to maternal health care in rural Northern Minnesota.
That is why Dr. Nynas spent hours of her personal time applying for a federal grant. And it was well worth it because in 2021, the U.S. Department of Health and Human Services’ Rural Maternity and Obstetric Management Strategies (RMOMS) program awarded Sanford Health a $3.67 million RMOMS grant to create a rural care network.
Sanford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
With the grant in hand, Sanford Health assembled a team that sets up appointments, offers transportation and facilitates nurse home visits. The RMOMS funds are also being used to develop three innovative telehealth programs including:
- An obstetrics video visit program that sends patients home with a doppler to measure fetal heart rate and blood pressure cuff.
- A novel obstetrics virtual hospitalist program that will allow local emergency departments to connect virtually with an ob-gyn in Bemidji to guide patient evaluation and stabilization during an obstetric emergency.
- A satellite clinic with Wi-Fi and telehealth equipment that will make many services previously available only at Sanford Bemidji Medical Center more accessible.
It’s important to educate patients about their medical conditions, give them the tools to take care of themselves, and empower them to share that knowledge within their communities. This has a far greater impact than any work physicians do at the bedside, said Dr. Nynas.
From this work, it’s no surprise that CNN named Dr. Nynas a 2024 “Champions for Change” pioneer. In an interview, she discussed this honor, and how she’s bringing medicine and health care to rural pregnant women in her home state.
AMA: As a Champions for Change pioneer, what impact do you hope to achieve through your work?
Dr. Nynas: When I started writing this grant proposal and thinking about what we could do, what kind of care do we need, what do our communities need, this quickly became a love letter for the women who I serve.
To be recognized for something I feel so passionate about is a tremendous honor. I want to make sure that we are not just breaking barriers but destroying those barriers that have always existed for rural women and improving disparate outcomes for both rural and especially Native American women. That's a huge part of our population up here, who not only respects traditions, but also embraces that culture.
AMA: What are the health inequities faced in rural communities?
Dr. Nynas: When you're dealing with small towns and very limited resources and traveling long distances—traveling two hours to come see me for an annual well woman visit may not be a big priority unless there’s a problem. But when we shift that way, soon there are problems that are not well controlled. In pregnancy, we see a lot of women dealing with the consequences of those health choices: chronic hypertension, type 2 diabetes, obesity.
To layer on, we have all the societal challenges. Poverty, limited access to food, inadequate housing, domestic violence, substance-use disorders and a lot of social concerns as well. That makes the care of these patients extremely complex. You must have systems in place that can meet those needs.
AMA: What are some of those systems you need to have in place?
Dr. Nynas: With our grant, we're really trying to put all those pieces in place so there's some fail-safe component. We have partners on our grants at Red Lake and Cass Lake Indian Health Services [IHS]. One of the first positions we created was a high-risk obstetrics care coordinator at each site who basically keeps the pulse on those high-risk patients.
In my office, we make a referral to them if patients have risk factors, or maybe it's just a social factor. Maybe it's a 16-year-old who doesn't have a lot of social support, and we want to make sure that she has the resources she needs to get ready for her baby and to make it to her prenatal care. Those nurses—or coordinators—are equipped with community partnership information on every single resource we have in our region.
If I have a patient who's presenting for care from International Falls, Minnesota, I know where I can send that patient if she needs food resources. I know who to contact for housing resources. We have so many wonderful organizations in Northern Minnesota that are doing really great work for their communities, but we didn't have anything tying that work to each other.
The RMOMS grant work is really trying to bridge those gaps on behalf of the patient so we can seamlessly connect patients to resources that are available where they live, increase access to behavioral health support, increase use of telemedicine to limit how much patients have to travel for visits and consultations, and really trying to meet women where they are. Instead of expecting a patient to drive two hours to see me for a 10-minute visit, I'm trying to bring as much of that care to them.
AMA: How often do you go out into the field?
Dr. Nynas: I go to Red Lake and Sanford Health Walker Clinic every month, and then we have a provider who goes to Cass Lake every month. Walker is about an hour south of Bemidji. It’s quite a big spread and all my partners do outreach at different locations throughout the region. We're looking at ways to potentially expand that, especially since four hospitals in our region closed their labor-and-delivery units in the last five years.
That’s really created a shortage of providers and very limited access. The more we can do that outreach and bring those closer connections, the better care we can provide patients when they do come to Bemidji to deliver or have their surgery.
AMA: What role does telemedicine play in this process?
Dr. Nynas: Telemedicine is a very critical piece of not just the work that we're doing, but also health care moving forward. There’s been such a growth in how people are leveraging technologies and developing new technologies that partner nicely with the technology we already use for those high-risk conditions.
Some care is better than no care, and if the decision is between no care and you doing some remote monitoring, even if you have a high-risk pregnancy, I'll take it. That’s where we're a little bit different than many of the other telemedicine programs. We've not limited telemedicine to just low risk patients. We're offering it to everyone who has a barrier.
AMA: What are your future goals with the work you're doing?
Dr. Nynas: The next big component of our grant work is implementing a virtual hospitalist program. We've identified two critical access emergency departments where we have a lot of patients present to for care. What we’re doing is putting telemedicine into those facilities.
If a pregnant patient were to come to Red Lake and had severe-range blood pressure, they could consult with me via video. I can see the patient's fetal monitoring, her contraction pattern. I can see what the patient looks like, and I can say: Hey, we have a hypertensive emergency, and she needs to transfer to Bemidji for monitoring, but she needs stabilization prior to transfer.
A lot of those conditions require prompt and immediate action. It’s important that we recognize that when you have emergency department providers in critical areas, they probably are very disconnected from obstetrics, and I wouldn't expect them to know how to do that.
We’re also expanding access to include satellites—brick-and-mortar clinics that already exist. We're starting this with our IHS partners in Red Lake and Cass Lake. We’re making sure there's Wi-Fi access, telemedicine equipment at our local clinic in Ponemah.
A medical assistant can check a patient’s vitals, help her get set up on some fetal monitoring if that's necessary. The patient can upload her continuous glucose monitor with the local Wi-Fi in the event she doesn't have a smartphone or broadband access at home. And then she can connect via telemedicine to clinicians in Bemidji or specialists in Fargo, which is our nearest tertiary care center.
The patient doesn’t have to drive to those places. And that improves adequacy of care, engagement and care. It’s something we're very excited about. We’re really kind of leaning in and saying: OK, let's see what telemedicine can do. Let's see what else we can do next. I'm really pushing that envelope a little bit.
AMA: What advice would you give to other doctors who want to make a difference in rural communities?
Dr. Nynas: Don't focus on the problem you have right now and how to solve it. What you need to do instead is focus on the care you want to deliver to that population 20 years from now. Set up for that future and what that system will look like to ensure that you have access to women's health care services, to prenatal care services and obstetric services in rural communities. We’re looking at provider shortages, we're looking at potential closures of more units, and we need to be prepared for that inevitability.
