Julie Gatewood

Julie Gatewood began working as a case manager at Mary Washington Hospital in 1987. Prior to joining Mary Washington Healthcare, she worked as a juvenile probation officer. She received her bachelor’s degree from Longwood University.

Julie Gatewood was interviewed by Jess Rigelhaupt and Abigail Fleming on March 11, 2015.

Discursive Table of Contents

00:00:00-00:15:00
Education at Longwood University and decision to become a social worker—Work experience as juvenile probation officer and with social services prior to becoming an associate at Mary Washington Hospital (1987)—Micah Ministries in Fredericksburg—Working with physicians and nurses at Mary Washington Hospital—Working in medical and pediatrics at the “old” Mary Washington Hospital on Fall Hill Avenue—More complex cases and higher acuity patients since the new Mary Washington Hospital opened in 1993—Questions of insurance and paying for medical care—Patient advocacy

00:15:00-00:30:00
Frequent changes and problem solving with Medicare, Medicaid, and insurance—Admission or observation status—Cultural diversity—Discharge planning—Working with organizations and agencies in the community—Discharge planning

00:30:00-00:45:00
Moss Free Clinic—Defining health—Mental health care—Debates about health care as a right or a privilege—Early experiences working at Mary Washington Hospital in 1987 in the Continuing Care Department, which focused on discharge planning—Early experiences at the new hospital—Core values and mission—Mary Washington Healthcare’s commitment to the community—Working with higher acuity patients that are part of the advanced medical care at Mary Washington Hospital, now a regional medical center

00:45:00-00:59:31
Primary care and public health—Communication in the organization—Enhanced integration and rounds with physicians, nurses, and pharmacists—Financial concerns—How social workers contribute to Mary Washington Healthcare—Meaningful interactions with patients—Summary ideas about Mary Washington Healthcare

Transcript

00:00:05
Rigelhaupt:
It is March 11, 2015. We are in Fredericksburg, Virginia at Mary Washington Hospital, doing an oral history interview with Julie Gatewood. To begin, Abigail Fleming will be asking questions and then I will come in later and my name is Jess Rigelhaupt. I will turn things over to Abigail to start.

00:00:25
Fleming:
Hi. I’m just going to go over some general questions about your work here at Mary Washington and your life as a social worker. The first question is what made you want to become a part of the case management team and just a social worker in general?

00:00:42
Gatewood:
When I was in college I actually started out as an elementary ed. teacher major. I went to Longwood, which is a strong teacher school. I grew up here in Fredericksburg. Once I got into the sociology and psychology and those classes, I really enjoyed that and decided I wanted to pursue social work. This was in 1977, when I graduated college and the jobs were really hard to get, more so than now. I did a practicum at a juvenile probation office and got a job with a juvenile probation officer right out of college. I was real lucky. I did that for several years and then eventually came back home and got a job here at the old hospital. I definitely loved this social work job better than any other. I worked at the department of social services too when I first came back up here. Unlike working out in the community, in the hospital it’s different—you have high caseloads, but it’s quick turn around and you get involved in some cases more so than others. I guess I’m a person who likes quick gratification. You go in and you meet somebody. Just today I had a new patient; I saw her today and she’s going to be discharged today. I sent her information out for rehab and already the rehab’s been in to talk to her. She’ll probably get approved and she’ll go today. It’s very quick. I had PT [physical therapy] come see her. Physical therapy worked with her and said, “Yeah, she would be a good candidate.” It’s just a very quick process. Unlike in the community, you might have somebody on your caseload for months and you don’t really see anything happen. You don’t see change. Change happens quicker here. I guess the thing that’s really nice about here is you have a lot of different disciplinary teams: the therapists, the respiratory people, the doctors, and the nurses, who all work together with the same goal. That’s really enjoyable and you don’t have that so much out in the community.

00:02:53
Fleming:
How did you, you said you worked as a juvenile—

00:02:58
Gatewood:
Probation officer.

00:02:59
Fleming:
Probation officer. [03:00] How did that influence your work here? What were your experiences like and how did they influence you here?

00:03:05
Gatewood:
It was a lot of diversity. I worked in Lynchburg and I worked in Newport News. We had all kinds of people there compared to here. I grew up here and this was a very small town back then. I saw lots of different populations as far as very poor, the drug use, and even prostitution. I mean there were crack houses. There were things in Newport News I had never even heard of before. It’s been good because when I came back here, all of a sudden, Fredericksburg has these same issues and you’re at least familiar with them and you’re not unaware of the different things. Fredericksburg has lots of resources now compared to back then for those different populations.

00:03:51
Fleming:
Can you talk about some of those resources and how you used them over your career?

00:03:55
Gatewood:
One of the best ones that we have now is Micah Ministries. I don’t know if you know about it or if you’ve heard of them. They are wonderful and I am just so impressed with what they’ve done. I’ve read in the paper, I think yesterday, they’re trying to move to a bigger building. They help so many people. We have a very big homeless population here. My own guess it is because I heard Prince William was trying to push those people out. I think a lot of those people came down here because we have lots of resources. It’s a big problem. We have families. We have people who live alone or are alone and they come in here sick and they have to have somewhere to go. The doctors—I’m a social worker so I know you can’t fix everything. The doctors will come to me and say, “Well, you need to find them a place to live.” And I say, “You know, I’m not a housing person.” They’ll say, “I don’t feel safe discharging them to the street.” Micah has been great resource because at least it’s a safe place. [Discharged patients] are dry and they’re warm. They help them get resources, insurance, permanent housing, and all that stuff.

00:05:07
Fleming:
What about, you said working with the physicians, they kind of expect you to be a fairy godmother and—

00:05:14
Gatewood:
I actually have a little wand on my desk. [laughter] When they come into my office I say, “Oh let me get out my wand.” For doctors, they don’t want patients to be readmitted. The readmission rate is a big issue now. For a long time we were decreasing the length of stay. We were getting them out in like three or four days, which is good from a financial standpoint. But then, these patients were coming right back in be cause we really hadn’t fixed everything. Now the focus is readmissions—the doctors get dinged and the hospital does too. They don’t want to see patients come right back. They come to us and want us just to find the perfect solution and there just aren’t perfect solutions out there. We try to find a pretty good one, but they want us to have the perfect solution so they don’t have to worry about them coming back, and that’s a big challenge. [06:00] In fact, the typical thing is you have families that are very dysfunctional. You have all these issues going on: the kids are taking mom’s money and just all kinds of things. They need to have the heat fixed. They want us to fix all that before they discharge them and I’ll just say, “Look, this is what they came from. This is the way they’re living. You know, I can give them resources, but we can’t just fix all that before they can go back there.” It’s a real struggle with the doctors.

00:06:36
Fleming:
Do you work with the nurses and physicians to try to educate them about what it’s really like?

00:06:42
Gatewood:
Yes. In fact nurses are also famous for saying, “You can’t send them home like that.” It’s neat because I’ve done this a long time. I think the more I’m around this floor for instance—I’ve been here a year and a half now—they have learned now with me, “Julie is going to say no they can go back.” But it is a reality. I mean lots of people think, “Oh my gosh, they don’t have heat. They have an outhouse.” But this is the way these people live. I mean, this is just kind of a reality thing. Lots of people here just can’t believe that people actually live like that out there, but there are still some that do.

00:07:18
Fleming:
You mentioned in the pre-interview that you worked at the old hospital. You were a social worker at the old hospital? You said you worked mostly medical, trauma, orthopedics. What exactly was your job at the old hospital?

00:07:36
Gatewood:
At the old hospital I just did medical and pediatrics. The old hospital actually didn’t have trauma. They did have an orthopedic unit that was very small. The old hospital was a much smaller scale, way smaller. It was purely medical stuff: people come in because they fall and break their hip. You have to get them into a nursing home for rehab. They’re sick with pneumonia and you send them home with home health. It was more simple and a lot easier.

00:08:04
Fleming:
So it’s a lot more complicated now that you’re in the larger hospital?

00:08:07
Gatewood:
Well it isn’t the hospital, it’s just health care. We have the trauma program and that means you draw those patients. Somebody on I-95 has a bad accident and they come in here. They have multiple injuries to all their extremities, their back, or their head. We have to find them head injury rehab, which we don’t even have here. Health South next door does take some brain injuries, but typically they go up north or down to Richmond. The other challenges with trauma patients are a lot of those are self-pays; they don’t have insurance. Then trying to find somebody to take them when they don’t have insurance is a big challenge. But those are more complicated cases and that’s with trauma, which has only been here, I don’t know, maybe seven or eight years? I’m not sure exactly how long. [09:00] What was the rest of that question, I’m trying to remember?

00:09:02
Fleming:
How you felt about the bigger hospital. You talked about it a lot bigger and it’s more complex.

00:09:12
Gatewood:
It’s bigger and there are a lot more complex cases. Like right now on this floor, the acuity right now, of all our patients—well, this is an oncology unit too. It’s a medical floor, but it’s also an oncology unit and we have so many people that are so sick. They come in here because they’re dehydrated, but they’ve got all these other conditions and they end up being here for like two weeks. We have gotten a bunch of them out recently. Even with the snow last week we were trying to hurry up and get some people out before the snow hit. Then when it snows people say they can’t go home. A lot of people have to go to nursing facilities and rehab places because they’ve been here so long. It’s just gotten a lot more complex with the kind of care that they need once they leave here.

00:10:00
Fleming:
You mentioned insurance, how people can’t or don’t have insurance. They can’t afford to pay. So how do you, as a social worker, handle the uninsured and the underinsured?

00:10:13
Gatewood:
That’s a big thing that we do. The good thing is we have a company here called APA [Advanced Patient Advocacy], which sees every person that is self-pay; they have to come see them. They actually screen them for, if they’re eligible for Medicaid, charity care, or disability because it benefits the hospital down the road once those things are approved. It actually pays retroactively for this hospital stay. It’s a win-win for the hospital and for the patient. That’s been a very good thing. But a lot of the times we are the ones who see these patients first and then make sure this company knows, “You need to come see this patient.” Like on this floor, if it’s a new diagnosis of cancer. I had a guy recently who was very young and who had metastatic cancer. They could expedite the Medicaid for that guy, luckily. Unfortunately, he went home with hospice and died like a week later. They probably still got the Medicaid approved, which still paid for his bills and was a relief for the family. We screen all the self-pays and refer them to Moss Free Clinic, which is a good resource also, and there are some other clinics too. Then we also refer them for medications. That’s a big issue. That’s probably one of the most frustrating things I deal with and it is not just for the self-pay population, but for people who even have insurance. So many medications now are so expensive. You may have insurance and the medicine is still going to cost you $500 and a lot of people just can’t afford that. The good thing is a lot of the pharmaceutical companies do have funding, which they should with all that they charge. They do have programs where they can help people with the copays. [12:00] We also have little prescription discount cards that we hand out to people a lot and that helps with the copay. Then for the self-pay population, we would just refer them to Wal-Mart for the $4 plan. We ask the doctors to write for generic medications because at least they’re $4. We do that kind of education.

00:12:20
Fleming:
When you work with the physicians and the nurses, do they know about the complexity of insurance issues?

00:12:28
Gatewood:
They’re learning. A lot of times they don’t if they’re newer to this, but I think a lot of them are learning. It’s been an eye opener for everyone. Over the last year or two it has really gotten a lot worse. Not to get on a political note, but with the whole Obamacare thing so many people have gone on that website and applied for this insurance because, “It looks like the one that would be right for me.” But then they come in the hospital and find out they have a $1,000 deductible, or it’s only going to pay fifty percent of my bill, or it’s not going to cover my medicines. Even though a lot of people are insured now, I’m seeing a lot of people who are really getting hit with a lot of expense because they’re insured, but how much it’s covering is not very good. That’s a big issue also.

00:13:23
Fleming:
Obamacare has really hit people pretty hard in the last few years?

00:13:28
Gatewood:
Yes.

00:13:33
Fleming:
Keeping with health insurance, you were talking about how patients may not have health insurance, but what about if they’re in constant need of medical attention? Like you have Micah Ministries and you have—

00:13:50
Gatewood:
Moss Free Clinic.

00:13:51
Fleming:
The Moss Free Clinic and you have these financial screenings, but if a patient keeps having to be readmitted to the hospital, how do you handle something like that?

00:14:01
Gatewood:
Honestly, we take care of those people. I mean, it’s not probably what the organization wants to do, but we just do. The thing I’m proud of is this organization has never turned away anybody because of payment. Some hospitals do. We’re here to serve the community and if this is what they use for their medical care, we do that. The emergency room tries to screen people who really could just be followed up outpatient in the community and not admit them, but some people, when they come in are just so sick, they have to admit them. Every time they come in—all the social workers here know a lot of these people. “Frequent flyers” is what we call them. They’re in and out a lot and we give them the same resource information every time they come in. A lot of these people are non-compliant. They go back home, continue their bad habits, don’t follow up with doctors, and there is not a lot we can do about that. They’re in and out. [15:00]

00:15:07
Fleming:
Do you recall President George Bush, his cutting the Medicare and Medicaid in 2004?

00:15:19
Gatewood:
Not exactly. [Laughter]

00:15:20
Fleming:
Okay. [Laughter] He apparently cut the budget for health care to the elderly and to the poor. But, I guess, do you remember, maybe, what it was like?

00:15:35
Gatewood:
No.

00:15:35
Fleming:
No.

00:15:37
Gatewood:
Over many years, we’ve seen so many changes with insurances, more so in the last few years. But all the insurances are paying less and less. Medicare, which has always been the one thing you could count on, has gotten bad. Like the last two years now: we’re all very frustrated because one of our easiest jobs used to be a patient’s going to go home today. They need oxygen and they need a walker. That used to be one of the easiest things we did. We would ask them which company they want and we would go set it up. Now, Medicare has this new thing where, depending on their zip code, they can only use certain companies because of competitive bidding. Certain companies bid for that. For Fredericksburg or for Stafford, Medicare is paying less for these items. You have to meet all of these qualifications to get them. I remember I had a lady not too long ago, who needed a hospital bed. Her only diagnosis was dementia and the [Durable] Medical Equipment Company said, “That’s not covered by Medicare.” I said, “Really? She’s bedbound.” We had to really fight it. We had to really dig in the chart for medical documentation to prove yes, she needs it. That’s Medicare. All the insurances have gotten much worse about not covering things and make it really hard to the point where sometimes you want to say, “Do you really need that walker? [Laughter] Do you really need that bedside commode?” You can go to Equipment Connections—I don’t know if you’ve heard about that place on Princess Anne St. and get free equipment. People donate it. Let’s say they went home with equipment and now they don’t need it or maybe somebody passed away and they donate it down there. We do send lots of people down there. Some insurance will only use one company, and I won’t mention their name. They’re the only provider and they aren’t located locally. We can never get them to bring equipment. You wait days. Sometimes we just tell the family, “Look, if you can afford to go pay for one yourself. Or if you want to to go to Equipment Connections and buy a used one, that’s sometimes your quicker option.” They need it when they leave here.

00:17:48
Fleming:
Speaking of fighting insurance companies, in-patient versus outpatient and observation stays.

00:17:56
Gatewood:
Big headache.

00:17:57
Fleming:
Big problem. Can you tell me about some of your experiences with patient versus observation stays? [18:00]

00:18:05
Gatewood:
Probably the biggest impact on me is they come in and let’s say they have a syncopal episode. You see them passing out. They’re ninety-four years old and they live alone. They don’t really meet criteria to be an in-patient, so they’re obs. But the doctor says, “I can’t send this little old lady back home by herself. They need rehab.” In order to go to a skilled nursing facility for rehab, you have to be an in-patient and you have to have a three-night stay as and in-patient. If they don’t have in-patient, then I have to try to find them rehab otherwise. You can get them into rehab if they had a recent stay here, within thirty days for three nights. That’s one thing we always look for and if they didn’t have that, Health South, our acute rehab hospital next door, will take people who are observation. There has to be appropriate diagnosis and there has to be a need. You can’t just send anybody over there. I have had some that they’ve taken for rehab and that’s your only hope and those are very challenging. [Pause] Or you talk family into taking the patient home with them and hope they can get some therapy for them in the home.

00:19:19
Fleming:
So we’re going to switch up a little bit. Looking at cultural diversity in the hospital, I understand you have something called a Blue Phone [for translation services]. How often do you use that?

00:19:31
Gatewood:
Not very often. I mean, probably once every three months. We have a couple different things. The Blue Phone’s great because I have had to use it, probably more so when I did trauma. We had a lot of trauma patients that spoke other languages and the families spoke other languages. In that case it’s great: you just bring the phone in the room, plug it in, and it can sit there the whole time they’re here. If a doctor comes in, if a nurse comes in, if a lab tech comes in, or if I come in, you just get on the phone and there’s another phone for them to get on. You just find out what language they speak and then you enter that. I just talk in my normal language and then they hear a translator who translates to them. So it’s good.

00:20:18
Fleming:
What about cultural diversity, physicians, nurses, social workers, anyone who works in the hospital, how do you guys, do you guys have programs for that? So how does that work?

00:20:30
Gatewood:
They have a cultural diversity program and they do educate everyone on different cultures, being respectful, and mindful of different cultures have different wishes or beliefs so that we don’t impose on them. That kind of thing. Probably a big issue is feeding tubes. Some cultures don’t believe in that or blood transfusions.

00:21:00
Fleming:
So have you ever noticed any types of issues or things that have concerned you based on race, ethnicity, gender, age, in the past or—?

00:21:12
Gatewood:
Probably the only thing would be feeding tubes. I have to be careful. There are some doctors who come from some cultures and they believe you can’t let a patient starve and they will use those words with the family. I’ve worked in the stroke unit, I’ve worked in trauma, and I’ve worked on this unit [oncology] and sometimes when they’re elderly and they’re at the end of their life processes, it’s appropriate for them not to eat as part of the dying process. It’s not appropriate to put in a feeding tube. That’s my belief and lots of people agree with that. Sometimes the doctors will say to the family, “They’re going to starve. We really should put this feeding tube in.” The family, they believe a doctor: “We have to do that.” They put one in and all that does is sustain the person much longer. That’s an issue, but not a big issue. I don’t mean to say it’s something that happens a lot, but it’s a cultural thing. I think it’s probably gotten better. I’m thinking about this as I’m talking. I saw it more so years ago. Not so much more recently and I think that’s a good thing. But you do see that.

00:22:35
Fleming:
So now people are kind of holding back their own beliefs when it comes to a situation where they’re supposed to be third person.

00:22:44
Gatewood:
Yes.

00:22:53
Fleming:
Again with cultural diversity, in talking about different religions and different beliefs people. Can you tell me about any experiences where you as a social worker, working with physicians and nurses or by yourself with the patient and their family, how do you personalize the care that you give to people that have specific beliefs?

00:23:20
Gatewood:
I’m very respectful. I’ve been through a recent death of my own with my mom and she did not want to to do the whole work up. She just wanted to be in her home and live as long as she could. I think part of it’s my background, part of it’s just my upbringing, part of it’s just me: I’m very respectful of whatever people’s wishes are. Everybody’s entitled to their own. They have to live with what they choose to do. That’s kind of how I feel about it. When I go into a room, I’ll say, “Here are your options.” If they choose something that I may not think is the right thing, I’m not going to say that to them. [24:00] I’ll say, “Okay. If this is what you want to do, then we will pursue that route.” You can’t really put your judgment into that.

00:24:09
Fleming:
Is it hard sometimes to think that, as a social worker, you know what could be best for the patient and they decide “That’s not what I want to do.”

00:24:20
Gatewood:
Oh yeah.

00:24:21
Fleming:
Or you think a patient should go to a skilled nursing facility and they say, “No I want to go home.” How do you handle that?

00:24:28
Gatewood:
I just explain to them that it would be safer if you went to a facility first and got the rehab. It would be very quick and you could be home in a week or two and then be better able to manage at home. Sometimes talking to people about that, they’ll consider it. Sometimes they’ll even consider it because they can still go from home. I’ll explain to them, “If you want to let the facility follow you at home, in case it doesn’t go well.” That does happen. They’ll get home and realize, “Oh my gosh. I can’t do this.” If they’ll at least agree to that sometimes that has worked. We’ve had people and the facility will call me and they’ll say, “Guess what? She came today.” I really talk to them. I do try to convince them to at least think about it because it’s better to do that than to go home and fail and you fall. We’ve had people who’ve laid there for a couple days. I kind of use that card too sometimes and say, “It’d be just awful if you fell and you were laying there for two days.” But in fact, we do see that a lot. I’m a good salesman I’ve been told. [laughter] A lot of people don’t want to go to rehab and so that’s one thing. I don’t really think of that so much as interfering with what they want. It’s really trying to point out the safest plan. That is our role: to try to have the safest plan for them when they leave.

00:25:55
Fleming:
So how do you reach out in the community, as a social worker? I know that you said before that you are involved with these different agencies, but how does the care management department really work in the community?

00:26:09
Gatewood:
We work a lot in the community. My Rolodex—people laugh and say, “You still use a Rolodex?” It’s just something I’ve always had. We deal with all the nursing facilities, all the assisted living facilities, all the home health agencies, and the durable medical equipment companies. We have social services, Micah, Moss Free Clinic—I mean there are so many organizations that we deal with every day and that’s just, that’s one of how many of us are there? There are like twenty of us social workers—no, there are twelve of us social workers. Every day, full time and we’re all referring to these places and making calls, many calls every day. It’s just constant.

00:26:56
Fleming:
Do you actually go out into the community?

00:26:59
Gatewood:
No. [27:00]

00:27:01
Fleming:
You just kind of work through—

00:27:02
Gatewood:
Oh no. We don’t have time for that. [laughter]

00:27:04
Fleming:
You’re constantly here at the hospital with discharge planning. Discharge planning, that’s a huge part of what you do?

00:27:13
Gatewood:
That’s ninety-nine percent. Luckily there’s a hospice social worker up here too, who just does hospice. Just today, the doctor came to me and said, “I’ve got this poor lady who is sixty-four years old and she’s got lung cancer. The oncologist has told her she has two weeks to live. She lives with her husband in a hotel because their house just burned down and I want you to put her in a nursing home.” Here’s a good example. I said, “A nursing home? Why can’t we have hospice go meet with them and explore options like they can have hospice at the hotel. Maybe they have family they can go stay with? I mean, if she only has a couple weeks, aren’t there some better options out there than a nursing home?” That’s being kind of judgmental, but I just think if that were me, I wouldn’t want to go in a nursing home in my last two weeks. I mean, shoot, if I’m staying in a motel, let’s go to Florida and stay somewhere nice for the last two weeks. [laughter] Hospice is going to go meet with them because they have more time. I don’t have time, a lot of times, with those more involved things because I’ve already done six discharges this morning.

00:28:24
Fleming:
When do you have time to—do you have time to sit with the patients for even in a small extended amount of time?

00:28:31
Gatewood:
Sometimes. We’re high census right now. That’s when it’s harder. When it’s high census it’s harder. I mean, sometimes, you do and sometimes we work overtime, which they don’t like us to do. We’re supposed to only work an eight-hour day. Sometimes it goes over because there are some patients you have to take the time with. We don’t have the time now and we don’t have the luxury that you would out in the community. We just don’t.

00:29:05
Fleming:
Can you share any stories about some of the programs you’ve worked with? Maybe a typical one or one that’s really impacted you as a social worker here at Mary Washington?

00:29:17
Gatewood:
You mean, out in the community?

00:29:18
Fleming:
Yes.

00:29:19
Gatewood:
Probably Micah is the one I’m most impressed with, only because they’re not a profit making organization. All these other places, like the facilities and home health, are all getting paid by insurances. Micah is an organization that came up out of the community from churches and I know gets funds from churches and different citizens. It has really impressed me with the amount of work that they do, even serving food to the homeless and finding clothes for them. It’s just amazing what they’ve done. I’ve been very impressed and I’ve had lots of homeless people who we’ve gotten in there. [30:00] In fact, it’s funny because when I call them, I’ll say, “Okay, I got one for you.” We actually have to fax a referral over and they have to look at it. Sometimes they’ll say, “Ah. They’ve been here before. They can’t come back.” Then we give them a list of other homeless shelters and places out in the community. Typically those people don’t do that and they’ll just go back out to the street. I’ve been very impressed with Micah. I’d say most of the time when I call them, they do take people and even people who are pretty sick. They’re supposed to be pretty able to manage, but I’ve had a couple that were more sick and they still took them. I’ve been very impressed with them.

00:30:39
Fleming:
What about Moss Free Clinic?

00:30:41
Gatewood:
The Moss Free Clinic is good too and they’re better than they were. For a long time they were the only clinic and the waiting list was backed up for people to get appointments there. I heard people talking about getting in line and standing in line forever. It really wasn’t a good, user friendly program. Then they opened other clinics. They opened the one on Bragg road, there’s one over on Princess Anne Street, and there’s one on Caroline. There are several clinics. There is Dr. Powell’s clinic. Several now, and I think that’s made it better. I think Moss finally realized they get a lot of backing from the hospital and the community and they had to make it better and more appealing and they have. I think it has been better. They do serve a lot of people and they’ve gotten better now when I call them. I have a discharge today and they’ll have an appointment for the guy for next week. It has gotten a lot better.

00:31:36
Fleming:
Good. So moving on to just health in general, how have you noticed, have you noticed any differences in how people measure health? Like what a healthy human being is?

00:32:04
Gatewood:
I guess I’ve noticed people are more into exercise than they used to be. Probably the funniest thing I’ve noticed is we have a lot more people in their nineties who are living alone and doing very well. We see a lot of that. People in their eighties and nineties who come in here with some minor thing—well, not minor, but like pneumonia or bronchitis—and we find out they’re living alone, they still drive, and they’re still very independent. We really push for therapy to get working with them right away. We want to get them back to that level. But I’ve been really impressed with how many people are elderly are taking good care of themselves—obviously, to still be living that well.

00:32:50
Fleming:
What about, has anybody ever, maybe with your studies in sociology, did you ever come across a definition of what health is? [33:00]

00:33:06
Gatewood:
Not that I recall. I think in general, to me, I think health is just everything in moderation. Exercise, eating right, and all those things, but there’s lots of people right, let’s face it, who have lots of different habits. And even if you live a healthy life, you still can get sick and have issues. The other thing about healthiness is with the insurances. We might hear, “We have different insurances this year and I never go to the doctor. I’m supposed to go in for a doctor’s visits.” They want you to do all these things, but you have the deductibles to pay first. I never go to the doctor, so why do I need to go to the doctor? But this is a good example of what the insurance is dictating. Anyway, I shouldn’t go off on that tangent [laughter].

00:34:09
Fleming:
What about social health or emotional health?

00:34:14
Gatewood:
There’s a big need here. We do have mental health, people who work here every day, twenty-four seven. We have Snowden across the street, but Snowden caters to a very small population. It does not serve elderly people. You need to be very well physically to go over there. If you have any disabilities you’re not allowed to go over there because they want people who are walkie-talkie and can do their group therapy and that kind of stuff. As far as anybody else, there’s a big lack of resources. We do have a lot of people who come in here who are in their forties, fifties, sixties, or older and who maybe are veterans or have psych histories. They need resources and there are none. Mental health, I think is the biggest. They did away with it years ago. I think it was in the late-1970s and that’s continued to be an issue. That’s a big lack of resources and the veterans—I won’t go there either, but there’s a big lack of resources for them too.

00:35:33
Fleming:
Was that just here in Fredericksburg, or are you talking about?

00:35:35
Gatewood:
The VA has a clinic here. I have found whenever we get veterans, it’s very hard to get them into the VA system. It’s very hard to get follow through. We all kind of joke about it: “Oh, they’re a veteran. Well I guess they’re out of luck.” I mean really, it’s very sad and when I see the stuff on the news about it: it’s true. [36:00] I feel bad for those guys because they’ve gone and fought for our country and yet when they need help, the VA really isn’t there. I find myself getting into a lot of political things here. I probably got to be very careful. [laughter].

00:36:23
Fleming:
I understand there is a huge debate about the ideas of rights versus privileges in health care. Did you come across that in your studies?

00:36:38
Gatewood:
Not really. Rights have become more so in recent years. I think, and as a matter of fact, one of the things that we do as a social worker every day is deal with patient rights. I have a patient who I just was getting ready to do her discharge and there’s a Medicare letter that says “Patient Rights.” It states that if she doesn’t think she’s ready for discharge, she can appeal her discharge. We do this with every Medicare patient. With lots of people, you go in there and give this to them and they say, “Oh, I really don’t think I’m ready for discharge.” I’ll say, “But the doctor thinks you are. You’re stable from every standpoint.” This is a patient rights thing. We have to do that by Medicare. We do strongly look at patient rights. It’s a good thing in a lot of ways because they come in here and sign the thing about their rights and that’s all very good.

00:37:43
Rigelhaupt:
Going back to 1987, could you tell me about your first shift at Mary Washington Hospital? I mean, it doesn’t really, exactly have to be the first shift, but you’re, as you began working here.

00:37:55
Gatewood:
I mainly liked it because it’s a very diverse group, as far as different types of doctors and different types of patients. It’s very interesting. There’s never a dull moment working here. Of course things have changed a lot since back then, but even back then it was just very interesting to me.

00:38:24
Rigelhaupt:
What did you see as the strengths of—I don’t know if it was care management, case management, if that was the exact name—the social work program that was part of the hospital?

00:38:33
Gatewood:
When I first came here, it was actually called the continuing care department and it was all just social workers. What we did was discharge planning, which is no different from today. I guess back then it was all the discharge planning. Every single thing you can think of when somebody came in the door, we did. Again, that’s really not that different except that the scale has gotten so much bigger now. [39:00] Back then we had four social workers, now we have twenty because it’s just a bigger population.

00:39:09
Rigelhaupt:
As a smaller community hospital when you started, I assume the acuity of the patients was lower? How did that shape your day-to-day work in terms of your work in what was called continuing care then?

00:39:22
Gatewood:
It was definitely an easier job and you could spend more time with the patient, like we were talking about earlier. You could definitely spend more time. I worked in the pediatric unit a lot and on the oncology unit at the old hospital. You could actually sit down with the family for a while and spend time. You actually got a little more involved, which was hard when you had some of the bad outcomes. You definitely had more time then compared to now.

00:39:54
Rigelhaupt:
When you came back in 1998, new hospital and it’s bigger. What do you remember about your first month maybe, I mean, as you returned and what it was like doing your job in the new hospital?

00:40:12
Gatewood:
It was very different. It was kind of like when you go home and you haven’t been home in a long time. And then it’s: “Wow! This isn’t home.” [laughter] The old hospital was very small. I don’t know if you’ve ever been in that building, but it is very small and it actually looks very different now. After they did the renovations on it, it doesn’t look like it did when it was the hospital. It was a more open thing, as far as everybody saw everybody all the time. It was more contact, more people contact, all the time. Whereas here, I see this as a much bigger building and it’s much more spread out with all the different west and north and south. We’ve talked about towers or silos. I think we’ve even said in our own departments, sometimes you feel like you’re in silos because the social worker or nurse over is in that unit and we’re over in this unit. You’re so busy. You don’t really have time to help. Well, we have to help each other sometimes. You’re just so separated, I guess is the word I was trying to say. It’s not as open as far as everybody seeing each other and working together. I guess. I don’t know. I’m talking about as the whole group.

00:41:29
Rigelhaupt:
What do you remember about a discussion of core values and mission when you started at the old hospital in 1987?

00:41:38
Gatewood:
I don’t know. I just thought, it’s an important thing to have and I think the hospital has definitely stuck with that, very much so through all these years.

00:41:48
Rigelhaupt:
It’s still something that’s talked about?

00:41:50
Gatewood:
Oh yeah!

00:41:52
Rigelhaupt:
Did it feel different or seem different, the way it was talked about when you started back in 1998 in what was a bigger hospital at that point? [42:00]

00:42:02
Gatewood:
No. I have to say with Mary Washington, I think they really have a commitment to the community and to the patients here. I really do. I believe that. Even though it’s gotten a lot bigger it’s because they’ve offered a lot more services. They’ve opened it to trauma and heart catheterizations and heart surgeries. They provide so many more services now than they did. Back when it was at the old hospital, people had to go to other hospitals in Richmond or Northern Virginia for those services. Now if you live in Fredericksburg, you can have everything done here. There’s a payoff to that. It’s big, but you do have everything that you can have done here. Even Spotsy [Spotsylvania Regional Medical Center] sends their stroke patients over here. Stafford sends a lot of their patients here because they don’t have some of the services we have.

00:42:58
Rigelhaupt:
One of the things that I’ve learned in this project is that higher-level clinical programs, cardiac surgery, higher level stroke, it isn’t just the procedures that are done. There’s a kind of cascading effect. You’re going to have to have a higher level ICU. That you’re going to have to have higher-level rehab. There’s a long continuation of care. In your experience, what has that meant for social work? How has being able to treat patients and do much more complex procedures here, as you described, changed the day-to-day work of a social worker?

00:43:38
Gatewood:
It really hasn’t changed it. We’ve had complex patients always, even before we had those programs. And really, in some respects, when they do the heart surgeries, those people are actually better than some of the patients who don’t have that kind of thing done. It’s more regimented as far as, “Okay this is what they do.” Those patients—and I’m thinking out loud—those patients actually are on a better program because they’re on a pathway. They have their heart surgery this day and the next day therapy is getting them up and walking. Unlike people who aren’t those diagnoses, they’re not going to get up the next day necessarily, which they should be. Are you following me? It’s actually easier as a social worker with those patients because they’re on a pathway and they’re going to get them up the next day. They’re going to do certain things within certain time frames because they are more regimented.

00:44:37
Rigelhaupt:
For lack of a better term, there are standard orders or goals?

00:44:40
Gatewood:
Yes.

00:44:42
Rigelhaupt:
And some of the patients admitted, say though the emergency department, there’s not going to be a standard?

00:44:49
Gatewood:
Right, right.

00:44:53
Rigelhaupt:
As you’ve alluded to, the hospital does acute care, as all hospitals do, but there are questions about primary care, access to public health. [45:00] And I presume as a social worker that that was part of your training and you think about those things differently than say a surgeon does, in terms of a procedure? And acute care hospitals in general in the U.S. have not necessarily emphasized primary care or public health as much as other organizations. Are there ways that you have seen the organization try to think about a continuum of care, primary care, public health?

00:45:39
Gatewood:
Yes. In fact, that’s changed more recently. And again, one of our roles is if they don’t have a primary care doctor, we’re supposed to help them get one. What we do is we have an organization called Health Link, which is part of the hospital and we can go to give the patient that number and tell them to call them. They actually call that number and based on their insurance they help them find a physician. So when they leave here, they have a primary care physician assigned and the secretary up front can fax the discharge instructions to that doctor. There is continuity of care as far as we make the appointment for them. It has been something they have been doing more regularly in more recent time. I think that’s part of the not wanting them to be readmitted. It’s making sure they have that follow up and continuity.

00:46:35
Rigelhaupt:
How did you learn about something like that and if that’s one program that comes to mind or others. That the organization says, “We’re going to do X because of Y.” I mean how does that information come to your department and throughout different units?

00:46:53
Gatewood:
Our department is probably one of the most integral departments in the whole place, I think. The organization does look at continuity care. They do look at the big picture and what best meets the needs of community. There are meetings—there are so many meetings. I wouldn’t want to be in a supervisory job because they’re in so many meetings. Or director, Laura, would be in those meetings and that’s where they have those conversations. That’s how it gets dispersed down to us and it becomes a part of what we do every day.

00:47:27
Rigelhaupt:
You talked about your department being integrated. You work with physicians, you work with nurses, and your department works with everyone. Has that been similar to when you started?

00:47:42
Gatewood:
It is similar, but it’s a lot more so now. In fact, we do interdisciplinary rounds now. Again, when it’s high census, like today, we’re not doing them. But we’ve actually been doing rounds with the doctor, the nurse, case managers, and sometimes the pharmacist. [48:00] We go from room to room and meet the patient and the doctor will say, “Okay. I think you’ll be here three more days. You are going to have therapy come work with you. This is your case manager, in case you think you might need anything else when you go home.” It is that kind of thing. That’s more of an emphasis too, more recently.

00:48:23
Rigelhaupt:
What are some of the benefits of interdisciplinary rounds?

00:48:26
Gatewood:
I think it’s really good for the patient. I think it’s good for them to see: okay, here’s your doctor, here’s your nurse, and here’s your social worker. But also, I think it’s good when everybody is there at the same time and we all hear the same information at the same time. If you don’t all do it at the same time, the doctor may go in and say, “You can go home in two days.” But then I go in there and they say, “He said I won’t go home until next week.” It’s good when we’re all in there and hear the same thing. Better communication.

00:49:02
Rigelhaupt:
When you started it was a single hospital, and now it’s a multi-hospital, multi-facility health care system. Has that affected the role of social work or case management, that you are involved with patients’ entering through multiple hospitals, through an integrated health care system?

00:49:26
Gatewood:
Not exactly. But the one thing that does come to my mind is, we used to not work weekends or holidays at the old hospital. Now we work every day. We take turns working weekends and we sign up for holidays. We used to be salaried. Now we are hourly, which is to our benefit because if you work holidays, you get paid more. If you work a weekend, you get paid more. If I go over today—because I’m in this interview—I’ll get paid. We have gotten bigger and there are a lot more of us, but we are fulfilling a service twenty-four seven more or less. We’re even on call. We have a beeper now for after hours. It’s a lot more involved and it’s not just a simple 8:00 to 5:00 job anymore.

00:50:24
Rigelhaupt:
Why do you think that is, in the sense, is the hospital more aware that the ways in which social work is more than medical problem?

00:50:36
Gatewood:
It’s not just the social work. We have an RN case manager and a social worker. With the in-patient status and the observation status, that’s also a big part of it. I think the bottom line is—I have to be careful in what I say. From a money standpoint, if somebody comes in to the emergency room and they’re observation, they want that person to be seen immediately by the case manager to see if they should stay observation or be in-patient. [51:00] If they’re not going to be in-patient, when do we discharge? That’s the nurses’ role. Then if I need to get them somewhere, they want it to be right away. There isn’t any time to waste, okay? That’s all money. If they sit here for days, we’re losing money.

00:51:30
Rigelhaupt:
On the flipside of that, it sounds also like they’re going to get referred to resources faster?

00:51:37
Gatewood:
Yes.

00:51:39
Rigelhaupt:
Which might not have been the hospital’s role twenty-five years ago.

00:51:44
Gatewood:
No, it wasn’t. They might sit here two weeks and may not get the resources. [laughter] It’s better. It’s definitely a better thing, but just very busy.

00:52:15
Rigelhaupt:
What would you most want the public to know about working as a social worker in the hospital?

00:52:28
Gatewood:
I guess, I grew up. Just like today, my second grade teacher is a patient. I went in her room and she remembered me and I remembered her. She didn’t remember my name, but she said, “I remember your smile.” It was just so funny and I’m getting her over to Health South, hopefully today. I’m hoping they’re going to approve her. I guess it just makes me feel good to help people. That’s why people become social workers. That’s what you do and we do that a lot here. That’s what we do.

00:53:03
Rigelhaupt:
What are some of the best practices that you think social work has contributed to the overall organization? That your perspective on patient care has shaped something that a nurse might do as a practice now or a physician?

00:53:21
Gatewood:
Probably, we spend a lot of time doing a lot of investigative kind of work. For instance, we had a patient recently and we couldn’t locate the family. I went back looking back through our old notes—we document with the computer and everything—looking to see if on a previous admission somebody had talked to a family member and has another number that we can reach this family. I finally found a number and got hold of the family. In the past, we were always the ones that did that. I would go and tell the nurse or the doctor, “Okay. I found it back here on this admission. If you look there’s a number right there.” I always do that. I always say, “Sometimes you got to look back a couple admissions ago and find another number.” [54:00] Again, we’re not here twenty-four/seven, but we are available. I try to help people think for themselves: “You could’ve looked back and there’s a number right there.” They can go ahead and reach the phone number. It’s more emergent, specially if somebody’s really crashing or not doing well. You need to reach that family right away. You can’t wait until the social worker comes in. We have tried to do that a lot and tried to help them think outside the box.

00:54:33
Rigelhaupt:
What are some of the things that make for the best day on the job?

00:54:38
Gatewood:
Not high census. [laughter] Seriously, we come in and we have huddle every morning. If Laura says, “Census is only 230.” We’re all like “Yay!” Every hole is covered, which means we’re all fully staffed. Then you know you’re going to get your job done, you’re going to do it well, you’re going to finish everything you need to finish, and you might even get some of your mandatory education things done. They’re over there waiting to be done and it’s just less stressful. You feel very accomplished because you know you get everything taken care of. Whereas on really busy days, you leave knowing “Okay. I didn’t get to this and I didn’t get to that. Tomorrow is going to be really bad because I’ve got to catch up.”

00:55:22
Rigelhaupt:
What would be some of the best patient interactions and maybe thinking about any of the different units you’ve worked in and actually if you could compare a best patient interaction at the old hospital to maybe the contemporary?

00:55:39
Gatewood:
I’m trying to think of the old hospital. I guess, probably, a good analysis would be I worked in the oncology unit there and I’m here too. I mentioned this in our phone interview: Dr. Essig is still an oncologist here and he is just wonderful. I remember one of the patients that I won’t forget. It was a patient, a lady like in her forties. She was just diagnosed with lung cancer and he went in and told her, “You don’t have long to live. You need to get you’re affairs in order.” I was in there with her and—oh my gosh—it was so sad. I remember crying and thinking, “Gosh. I probably shouldn’t be crying.” I had another case too in the old hospital. It was a pediatric case with a child who had a fatal illness. Again, I was crying and the family is right there and I’m thinking, “I shouldn’t be crying.” But I’ve learned, comparing then to now, that it’s okay to do that. It’s okay to be human. I mean, we see lots of sad things here and I think the compassion and seeing that people are real is helpful to the patient families. Rather than they see somebody that doesn’t care or they think doesn’t care and doesn’t have any feeling or emotion about it. I hope that answered your question. [57:00]

00:57:05
Rigelhaupt:
What would be some of the things you would want the public to know about Mary Washington Healthcare as an organization and might not be common knowledge?

00:57:16
Gatewood:
I don’t know if people know, I think they really are committed to help serving the community. I don’t really know if people know that. I’ve heard lots of people say negative things about Mary Washington. But I think they really are. I’ve seen the board and all these people who’ve been around a long time and Fred Rankin just recently left. From everything I’ve heard about the new CEO, I think he’s very committed. I’ve been very impressed with how committed they are to serving the community and I think they have served the community. I think the community is lucky to have this organization.

00:57:50
Rigelhaupt:
Are there things that you would point to in terms of serving the community that are resources that have been—that you’ve been able to draw upon in your day-to-day work or in social work that you know came from that commitment to the community, as you described?

00:58:07
Gatewood:
The Moss Clinic, Micah, the self-pay, and the trauma. The trauma has definitely been a big one and the heart surgeries, which brought things here for the families. Even having Health South building next door—that’s not really Mary Washington, but it serves the families. They don’t have to go away now for rehab and I think the community is lucky to have all these resources right here.

00:58:38
Rigelhaupt:
We’ve asked a lot of questions all over the place and the way I like to end is to ask a last question that is actually two questions. Is there anything that we should have asked that we didn’t and is there anything you’d like to add about the history of Mary Washington Healthcare?

00:58:58
Gatewood:
I can’t really think of anything. I just think it’s a very good organization. I think the hardest part in this job is the whole insurance thing and lack of resources for mental health, but I don’t know what you do about that.

00:59:21
Rigelhaupt:
A problem no one single organization can fix.

00:59:25
Gatewood:
No, no.

00:59:29
Rigelhaupt:
I think we’ll stop there. Thank you.

00:59:31
Gatewood:
Okay. Thank you.
[End of Interview]

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