BOOTHBAY HARBOR, Maine — Tourists arriving in this oceanside village, a 12-mile drive down a winding road off the main highway, are greeted by a sign bearing a large red heart. “Help! Save St. Andrew’s Hospital,” it says.
On this isolated peninsula, in the oldest county in the state with the oldest median age in the United States, citizens are mobilizing against the planned conversion of the 105-year-old hospital into an urgent care and rehabilitation center. When St. Andrew’s closes its 24-hour emergency room and stops admitting patients overnight on Oct. 1, the nearest hospital will be 18 miles away, up that winding road.
Residents say they feel betrayed by the nonprofit company that owns the 25-bed hospital where many of them were born.
The change “scares me to death,” said Marie Snow, 76, a former switchboard operator at St. Andrew’s. “I’ve been telling people, ‘We need to get real friendly with our funeral director.’ ”
Hospital leaders say the lightly staffed emergency room can no longer assure safe care and continuing to operate it doesn’t make financial sense. Most patients using the emergency room, they note, could be treated in an urgent care center or by primary care doctors, at much lower cost.
What is happening here highlights the strains on the nation’s rural hospitals, which provide care to 54 million Americans, according to the American Hospital Association, and are often the largest employer in small towns.
Because their patients are disproportionately older and poor, rural hospitals rely on government health insurance programs, which pay less than private insurers. They also have to spread the expense of equipment purchases and staff over fewer patients, causing many to lose money, said Dr. Karen Joynt, an instructor in health policy at the Harvard School of Public Health who studies rural hospitals.
No other hospitals have closed recently in northern New England, and just one rural hospital in Massachusetts has — Hubbard Hospital in Webster became an outpatient facility in 2009. But more rural hospitals will probably confront similar decisions in coming years, Joynt said.
Despite regular charitable contributions from the community, St. Andrew’s has reported losses in five of the last 10 years and has been paring back during that decade, previously removing surgery and maternity services.
The new urgent care center, open seven days a week, 10 hours a day, with extended hours in the summer, will handle minor trauma such as broken bones and nonemergency illnesses; the facility will also offer rehabilitation and physical and occupational therapy.
An average of 12 patients a day visited the emergency room in 2012, but only two or three a day truly need emergency care, said James Donovan, chief executive of Lincoln County Healthcare, which owns St. Andrew’s.
Dr. Tim Fox, director of the emergency department, said on some winter days he works a 24-hour shift and sees one patient.
But locals tell emotional stories of the emergency care they received. There’s Tammy Chubbuck, 47, a hotel manager who has chronic heart disease. St. Andrew’s saw her through three heart attacks.
Or Daniel Jameson, 87, a Korean war veteran and retiree from Raytheon Co. who once cut off the tip of his finger with a saw. His wife drove him down the road to St. Andrew’s, where doctors reattached it.
Most residents don’t call ambulances because they live so close to the waterfront hospital, which overlooks an inlet full of bobbing sailboats. Now the nearest emergency room will be at Miles Memorial Hospital in Damariscotta, a small hospital itself where patients cannot stay longer than four days. Many will end up at a larger hospital in Portland 54 miles away.
Townspeople are afraid of losing doctors who know them and linger to chat, of waiting in long lines at Miles’s emergency room, of not being able to sit with a dying parent during lunch hour. They’re writing letters to the editor, raising money, even interviewing directors of other hospitals to learn about community health care.
“They have not given up,” said Lisa Conn, a nurse at St. Andrew’s. “They have surprised me with how strongly this community feels about saving the hospital.”
Boothbay Health and Wellness Foundation, a community group, is most vociferously challenging the closing. Yet, its chances appear remote. Short of “chaining ourselves to the door,” said foundation president Patricia Seybold, the group may not succeed. She said she is not ready to divulge any future legal strategy.
“Nothing can fill the gap of an emergency room down here,” said Dr. Nancy Oliphant, the only private practice doctor in Boothbay and a former St. Andrew’s physician.
Oliphant told of a patient having a heart attack who drove himself to her office with his wife, who was in a wheelchair and could not be left alone. Oliphant and her husband got the man and his wife to the emergency room, then drove the couple’s car back home, parked it, locked their garage, and closed the house.
“That’s not going above and beyond the call of duty,” she said. “That’s just small-town medicine.”
But medicine is changing, even if that means losing “some of the things that are really nice about small towns,” said Dr. Mark Fourre, medical director of Lincoln County Healthcare. The company owns both St. Andrew’s and Miles and is part of MaineHealth, the state’s largest hospital network.
“People in Boothbay are exactly right: You have to wait longer, and it’s inconvenient to drive to Miles,” he said, while noting that the changes are in line with national trends.
Fourre, however, said patients will be safer going to Miles, where trauma teams are available and physicians aren’t alone during an emergency, as they are at St. Andrew’s. Specialists such as pediatricians and trauma experts need to be on hand, he said, so doctors don’t treat patients they are unprepared for.
A 2011 study published in the Journal of the American Medical Association supports the idea that small rural hospitals overall provide inferior care. Researchers examined 1,268 of the roughly 1,300 critical access hospitals nationwide — a federal designation for particularly isolated and small hospitals such as St. Andrew’s — and found they provided worse care and had higher mortality rates than larger counterparts.
An April study led by Harvard’s Joynt found that mortality rates at these hospitals climbed between 2002 and 2010, suggesting they are getting worse at caring for patients with heart attacks, congestive heart failure, or pneumonia.
While Miles is also a small rural hospital with few specialists, Fourre said it is a more robust operation than St. Andrew’s.
Joynt said the closure of an emergency room like St. Andrew’s — when another hospital is accessible, if not convenient — is unlikely to harm the health of the community, though it can have an intangible impact on the town.
The closing will place more responsibility on Boothbay Harbor’s three-ambulance emergency medical service, which Lincoln County Healthcare is counting on to keep patients alive while they are transported to Miles.
Previously staffed by volunteer or part-time emergency medical technicians and paramedics, the service now has to hire full-time staffers.
“We don’t like this,” said Scott Lash, operations manager of Boothbay Region Ambulance Service.
The service used to cost taxpayers $100,000 a year. It will now cost $400,000 annually. Lincoln County Healthcare provided a donation to the four towns served by the ambulances. Lash said the money will offset the increased cost in the first year, but residents fear that source of funds will not last.
And Lash says residents may not easily learn the distinction between emergency, urgent, and primary care, as Lincoln County Healthcare hopes they will.
“What do you do at 3 in the morning when the elderly person has hit their lifeline . . . not because it’s an ‘emergency’ but because they just can’t manage their chronic illness at home?” he asked. “Before you know it, you’ve got a packed ER and an ambulance service that’s overwhelmed.”
Simply put, old habits die hard here. With tears in her eyes, Frederica Luke, 66, a former administrative assistant at St. Andrew’s, said she and her husband no longer want to retire in Boothbay. She recently waited three hours for her mother-in-law to be seen at the Miles emergency room.
She is not convinced by talk of preventive care and quality. Things have always been done a certain way in Boothbay, and she doesn’t like the scent of change in the wind:
“We Mainers,” she said, “we don’t adapt.”