When asked about the current challenges regarding delivering care in a rural hospital setting, Jason Cleckler, CEO of Middle Park Health in Kremmling, Colorado, does not mince words.

“This labor market the past few years of the pandemic is something I’ve never seen before,” he said. “The main concern that I have from day-to-day is about our workforce."

Cleckler has been CEO of the critical access health system for about two years and has been a hospital CEO for nine years. He said to be competitive, his system pays in the 75-100% percentile of nursing and other professional wage scales. With support from their board of directors, Middle Park Health has also invested about $4 million into employee pay and benefits. This includes no increase in health insurance premiums for the past three years. Also, they have increased their starting entry, nonclinical wage to $17.50 an hour, up from $13.

Still, the health system has a 15-20% vacancy rate. It would be as high as 25% without the help from temporary nurses and therapists, known as travelers. Travelers working the past two years of the pandemic under two-to-three-month contracts can nearly double their income, observed Cleckler. According to the American Hospital Association, some hospitals report hourly nursing rates of up to $240 an hour.

For rural hospitals, the nurse recruiting problem is exacerbated by a lack of accessible housing. Cleckler's system rents five condominiums and houses just for use by travel and on-call staff. Before the COVID pandemic, it was possible to recruit traveling nurses attracted to the outdoor lifestyle the community offers in the mountainous Granby Lake area served by Middle Park Health. But with the housing shortage, things have changed.

“We have travelers who extend their stay because they like it here," Cleckler said. "But to hire on, they’d give up making $150,000 a year and drop to $80,000 a year and have to provide their own housing. It’s hard to pull that back.”

Cleckler reports that the Grandy Lake region has seen home values jump as much as 50% in many towns in the West. Much of this pressure is driven by out-of-state buyers snapping up second vacation homes. Also, as with many resort locales in Colorado, owners can make more renting their properties in the short term rather than committing to yearly leases. Middle Park Health serves a region rich in outdoor recreation, including downhill and cross-country skiing, snowmobiling, fishing, and hiking.

“To give you an idea about the lack of affordable and accessible housing, we recruited a full-time orthopedic surgeon who’s having a challenge finding a house he can afford,” said Cleckler.

The housing shortage was worsened by the East Troublesome Fire in October of 2020 that destroyed 350 homes. Consequently, according to Cleckler, builders are three to five years out constructing new homes.

Despite these challenges, Middle Park Health is better off than many rural health providers. The same markets driving home sales also provide a payer mix (ratio of private/commercial insurance to Medicare/Medicaid) that would be the envy of any health system. The system generates about 70% of its revenue from an extensive outpatient services network. This, along with federal CARES relief funding approved by Congress, has helped Middle Park Health better weather the tremendous pandemic financial pressure on rural hospitals.

On the inpatient side, the system currently splits its 25 critical access beds between two campuses, one of only less than a half dozen critical access hospitals to do so in the U.S., Cleckler estimates.

“We're going to be adding a third inpatient site, splitting our critical access beds three ways to serve our geographically large service area better," he said. "I wouldn't be surprised if we weren't the only critical access hospital in the country taking such a strategy."

The long-term impact of the Covid pandemic, Cleckler said, is that he thinks the days of nurses and other staff spending five to ten years — much less an entire career — with a single employer is changing. The norm seems to be evolving into two to three years. Millennial staff, he has observed, want the flexibility to take more time off and travel to see the country.

Cleckler rose through the nursing ranks to become a hospital CEO, so he can relate to hands-on caregivers. To better meet the needs of his changing workforce, he said he has recently formed an employee advisory committee of front-line staff. He wants them to give him input on how Middle Park Health can be a better employer.

“Employees want more control of their schedule and benefits,” said Cleckler. “When you’re a nurse, it's not always about money; it's often about being appreciated."