Health on the Map: Collaboration within Rural Health Care

Mount Marty University President, Marc Long, recently joined Wende Heckert for Health on the Map, a podcast that explores rural health care in the United States. Heckert is a family nurse practitioner in Nebraska and owner of Hecker Health Center, LLC. She earned her bachelor’s degree from Mount Marty, two Masters of Science in Nursing degrees from the University of Nebraska Medical Center and Nebraska Wesleyan University, and a Doctorate in Nursing Practice from the University of Tennessee Health Sciences Center in Memphis with a specialization in forensic nursing.

This conversation has been taken from the original podcast and edited for length and clarity.

Can you walk me through how you became interested in nursing and how you ultimately got to the point where you opened your own practice?

Well, the easy part about being interested in nursing was my dad's little sister was a nurse, and she was the one that introduced me to that because everybody in my family was business related. So we were the two medical—the two lone medical people. And I know when I had to make a choice between Mount Marty and Augustana, she was a little partial and biased to Augustana because that's where she went to school. But I chose Mount Marty, and I ended up choosing Mount Marty because it just always felt like home. And that was kind of the thought process because, you know, becoming a nurse was pretty much a lifelong goal and went on ahead and did that—graduated 30 years ago this week, I think. 

Great! Happy anniversary. 

Yeah, class of 94. So yeah and through being a nurse, working in hospital settings, I also did know one of my colleagues from the small town where I grew up in Neely, Neb., who was finishing her nurse practitioner degree. That was a pretty new one. In fact, I think she was the second class to graduate from UNMC, if I remember correctly. She was the one that said, “Hey, I think you'd be good for this.” The physician that I worked around a lot said, “I think you'd be good for this.” And so that's how I ended up becoming a family nurse practitioner.

Can you explain maybe a little bit about the evolution of advanced practice nursing since you started your career, and how you interact with specialists in the health system in Nebraska today?

Absolutely. In fact, back in graduate school from 96 to 98, we were starting the process of trying to get full practice authority in the state of Nebraska. And I want to say it was at least a good 20 years later by the time we finally got it all hammered out and ironed out. It was a very big evolution, in the fact, that we started down a path of just trying to get that practice moniker at the tail end of our names. I know when I started out, we were actually ARNPs—so Advanced Registered Nurse Practitioners. And so we, in the evolution of things, changed it to APRN—I think it was in 2000—in order to start with the umbrella of practice in Nebraska, which was making sure that we all fall under the APRN guidelines whether you're a CRNA, a CNM, a CNS, or an NP like most of us are.

In the rural health arena, we kind of did everything. We would see the nursing home patients, we'd go to the clinic, we'd do hospital rounds, [and] we'd take call in the ER, that sort of thing. And as we moved to a more specialist-based care model, it seems like over probably about the last 10 to 15 years [is] where people tend to have more specialists involved in their care than they ever have before.

I have noticed that full practice authority started coming out just a little bit more to the forefront. We were able to do some lobbying, get some things handled, and now full practice authority in the state of Nebraska is the fact that we can open up our own clinics—we can work independently.

But what I want to preface is we always work in collaboration with everybody that we encounter because we're not in a vacuum all alone, in a silo all alone. We have to make sure that our patients are being taken care of in the best possible way. And so sometimes that does mean having to bring a cardiologist on board [or] having to bring a psychiatrist on board for mental health issues. But because of the fact that we don't have an incredible amount of specialists in our truly rural Nebraska counties—I know Norfolk's considered to be a rural area depending on who you're talking to—but there are some places where just even access to a healthcare provider without seeing them on the television you might have to drive 60 miles to get there. And so that's been a tremendous hurdle to overcome.

One thing I've learned about health care just as an observer is that it's constantly changing. I love the fact that you have a family practice clinic. I know that physician practice clinics used to be commonplace and are less and less so now that the health systems usually own those practices. Can you tell me what the opportunities and challenges are to owning your own clinic in a rural area of the country?

Probably the biggest one is reimbursement through insurances. I would say that that's probably a large aspect of it simply because of the fact that most insurances still pay us only 85% being a nurse practitioner unless I bill under, say, a supervising/collaborating, however you want to say it, physician. But the thing is then we don't get credit for our work. So, that I knew when I was setting this up that I was going to be taking a hit on some of the reimbursement processes, and that's completely 100% ever changing and ever evolving. Anytime I think I've got it figured out, they give you a new code that you need to use.

What are some of the opportunities that you see in practice?

As far as?

Yeah, just in terms of how it's different from a nurse practitioner. When did you actually start your clinic? What year?

10 years ago this fall.

Okay, great. So what are the opportunities that you have in finding patients, working with patients, that maybe people who are in working for a bigger corporate clinic don't have those opportunities?

I think it's personal touch more than anything, simply getting to know my patients and their families. I have found that advertising while it works very well, the best thing that we have is word of mouth. And so if someone is satisfied with your care, they will tell somebody that they love or respect that they're satisfied with your care. And that's how you pick people up.

There are still some people that like the old model. And what I mean by the old model is that you have one person who kind of knows you from head to toe, inside and out, can remember your surgeries, can remember some of your medications, maybe the pharmacy that you go to, that, “oh yeah, you're probably going to need that test next time you come in,” and make it a little bit less technologically based, if you will. Although that's the crux of family practice right now, remembering that we have many generations using many different forms of communication. I actually had somebody ask me for a handwritten script the other day!

Yeah, you don't see those very much anymore.

I can't remember the last time I physically wrote out a prescription except when my computer was down that one day!

Yeah, that happens for sure. So what does a typical day look like for you? I know not every day is typical, but sort of a typical day in terms of patient care and administration.

That's split up depending on what's going on that day. So some days I may be really super heavy with taking care of patients. The one nice thing about running an independent practice is I can decide whether or not I need 15 minutes with a patient versus an hour because that might be something where we need to be making some referrals, some calls, doing some education, you know, whereas sometimes in your bigger practices you're told, “Okay, you've got 10 minutes, go on to the next person. You’ve got 10 minutes, go on to the next person.” And that's the part that I don't really like. But, you know, it's one of those things where I sit down after I've encountered with the patient, and I try to do all of their prescriptions [and] all of their billing sometimes before they even leave the suite. 

So from your perspective, what are the biggest challenges in rural healthcare now?

Probably for patients, I would say it would be access. For us, it's probably more the day-to-day stuff. Computers have made our lives so much more simple, but they've also made them so much more treacherous simply because of the fact I find myself on the computer more than I am seeing patients. And that part I don't like. But at the same token, I know it's a necessary part of doing what we do.

Let's pivot and talk about your interest in forensic nursing. First of all, what is that and how did you become interested in it?

Actually, I took care of a patient a lot of years ago as a nurse that it was one of those deals where we just didn't end up collecting evidence on something that ended up being a case. I've always been interested in that sort of stuff. In a former life, I kind of wanted to be Quincy, you know, the old television show.

I do, I'm old enough to remember that.

I was going to say there's going to be three people out there that know Quincy!

But then I figured out you had to go to school to be a physician, a surgeon, and a pathologist and go get your law degree. And I said, no. So Nebraska Wesleyan University started a class for masters prepared people in forensic science. I took the criminal investigation track mostly just for knowledge at that point. I just wanted to know how to better serve our populations as far as those who have been victims, witnesses, perpetrators, that sort of thing when it came to forensic cases. And also just that whole prevention of intentional and unintentional injury is the crux of what I do as a forensic nurse. Through getting that degree at Wesleyan, then, I had the opportunity to go back to doctoral school. And at the time, I think it was the only program in the US at University of Tennessee Health Science Center. And I focused in on forensic nursing as the crux of it, and prevention was key. Prevention was the thing.

Interesting, is that part of your consulting work now?

Yes, some of my consulting work deals with nursing, with being a nurse practitioner, but a majority of it deals with prevention of injury.

Wonderful. All right, Dr. Wendy Heckert, I have a feeling that you probably have a patient waiting on us to finish, so I appreciate your time today. Thanks for the information. Anything else you'd like to add?

Just that, of course, thank you so much for giving me this opportunity. Mount Marty has always been an awesome institution and will continue to be an awesome institution. If anybody's looking to receive a nursing degree, a nurse practitioner degree [or] advance into a doctoral degree, this is the place to go. And you guys did not pay me to say that!

No, that's true. Thanks for that. And we're very proud—Mount Marty University is very proud of your success, Dr. Heckert, and we look forward to seeing what the future brings. Thanks so much for joining us today.

Health on the Map is a production of Mount Marty University Nursing and is available for streaming on Spotify, Apple Podcasts, and YouTube. To learn more about Mount Marty, South Dakota's Catholic University, visit mountmarty.edu/nursing.

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ABOUT MOUNT MARTY UNIVERSITY

Founded in 1936 by the Benedictine Sisters of Sacred Heart Monastery, Mount Marty University is South Dakota's only Catholic institution of higher education. Located along the bluffs of the Missouri River in Yankton, with additional locations in Watertown and Sioux Falls, Mount Marty offers undergraduate and graduate degrees focusing on student and alumni success in high-demand fields such as health sciences, education, criminal justice, business, accounting, and more. A community of learners in the Benedictine tradition, Mount Marty emphasizes academic excellence and develops well-rounded students with intellectual competence, professional and personal skills and moral, spiritual and social values. To learn more, visit mountmarty.edu.