In March 2025, Nowata resident Joe Thornbrugh ended up at Ascension St. John Medical Center in Tulsa. Delayed treatment for what turned out to be a kidney stone led him to experience sepsis, a life-threatening condition.
While hospitalized, Joe developed bed sores, making it impossible to walk. He was sent to different hospitals in Broken Arrow, Fairfax and Bartlesville for several months. It wasn't until he landed in Nowata's critical access hospital that he started to feel better.
"I'd see my grandkids every day, my wife every day," Joe said. "I thought, 'I want to go home, I want to get better. This is why I'm here. This is what I've worked my whole life for.'"
Joe spent 100 days at Ascension St. John Nowata through its swing bed program, which allows patients to transition from an acute hospital stay to skilled rehabilitation while remaining in the same hospital. He was two minutes away from his wife, Krista Thornbrugh. After he received wound care and physical therapy, she got to see him walk again.
"It was one of the best things that I don't know if we would have ever been part of anywhere else. And I'm just so thankful," Krista said. "I couldn't imagine [this community] losing … the ability to have the kind of care that Joe had."
Ascension St. John is seeking federal approval to turn its Nowata hospital into a rural emergency facility, which would mean ending acute inpatient and swing-bed services. Congress established the designation in 2020 to help maintain local access to outpatient and 24/7 emergency services amid growing concerns over hospital closures. Rural emergency facilities receive a monthly payment of around $295,000 to do this.
The nonprofit health system said the move would support the long-term viability of local healthcare. But many residents oppose the change, arguing that inpatient care is essential for Nowata County, where residents are older and more likely to live in poverty than Oklahoma's population as a whole.
What Ascension St. John says is driving the change
StateImpact requested an interview with Ascension St. John officials and received statements from a spokesperson. They said conversations with staff and community members about the transition began in April, and there are no planned layoffs.
Rural emergency hospitals can't exceed an annual per-patient average length of stay of 24 hours. After the transition, patients who need to be admitted to the hospital would be sent to Ascension St. John's locations in Bartlesville, Owasso or Tulsa, the spokesperson said. Transfers to these facilities would be paid for by Ascension St. John, and the spokesperson said it is working closely with EMS partners to ensure they are smooth.
The rural emergency model has created challenges for local EMS in other states. Last year in Mississippi, county officials demanded its ambulance service stop picking up patients from a hospital in Batesville, which became a rural emergency facility in 2023, to transfer them to higher-level care. They argued numerous transfers were leaving county ambulances unable to respond to emergencies.
Nowata Fire Department Fire Chief Brandon Jarvis said the city's EMS serves all 581 square miles of Nowata County. It has one ambulance that runs 24/7 and a backup used when the other vehicle has an issue or requires maintenance. It receives around 700 calls a year.
Jarvis, who joined the department about a month ago, said he would like to see the community get another ambulance to help handle emergency calls and transfers during the daytime so the primary ambulance can stay in the county. That could cost $250,000 to $350,000, he said, and would require him to hire part-time staff members.
"If it ended up being multiple transfers a day out of there, it's going to be hard to keep up with the load with our current resources that we have," Jarvis said.
The Ascension St. John spokesperson said that, since 2020, the Nowata hospital has experienced a 58% decline in inpatient admissions, while emergency department visits have increased by 12% since 2022, "highlighting a shift in patient utilization patterns." They said the rural model better reflects the community's needs.
Hospital cost reports show that the facility's average daily inpatient census over the past decade is 4.85 patients. Though the hospital saw modest increases during the COVID-19 pandemic, this number has remained generally consistent. StateImpact asked the spokesperson for clarification on the data they cited. They referred back to their original statements.
Tanner Holt, president of Ascension St. John Jane Phillips in Bartlesville, and Jason McCauley, the Nowata hospital administrator, met with two members of the recently formed Save Our Hospital community group June 8 at the Bartlesville facility. Save Our Hospital has collected about 1,000 signatures around Nowata County in favor of the hospital maintaining inpatient care.
In a recording obtained by StateImpact, Holt said Ascension didn't push them to make this transition. They wanted to be proactive to ensure Nowata is sustainable.
"There's obviously money that is associated to that, and that will go to the [profit and loss] for Nowata every single month. It will allow it to be profitable," Holt said. "And as a hospital is profitable, you're taking kind of a laser eye of a corporation off of you, saying, 'Hey, do we need to close this? What do we need to do?'"
According to tax records, the hospital has had some profitable years over the past decade. But it lost about $1 million in fiscal year 2023 and most recently, around $200,000 in both fiscal year 2024 and 2025.
"The alternative is somebody coming to Jason or I and saying, 'You just got to close it. You've been bleeding far too long,'" Holt said. "And the only reason Ascension hasn't done that is because they've got a very strong balance sheet."
In May, Ascension reported a net income of $621 million through the third quarter of fiscal year 2026.
McCauley said the rural emergency model has surfaced in past discussions with the Nowata hospital's advisory board. A Save Our Hospital member asked why the board wasn't made aware of the transition until the application was filed.
"We knew this was going to be a big change for folks," Holt answered. "The way I look at it is, do you get somebody's permission to throw them a life raft when they're drowning, right? And that is what is happening here."
StateImpact asked the Ascension St. John spokesperson for comment on this meeting. They referred back to their original statements.
How the rural emergency hospital designation could work in Nowata
Over 1,500 health care facilities in the U.S. are eligible to become rural emergency hospitals. About 50 total have obtained the designation, and six are licensed in Oklahoma.
For some facilities, the model has worked. Clinton Regional Hospital closed at the end of 2022 after AllianceHealth, the private company managing it, decided not to renew its lease. It reopened through support from the city and is now running as a rural emergency hospital.
"It's not clear that there was a problem in Notawa that required this particular program," said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.
If its application is approved, Ascension St. John Nowata would become the second critical access hospital in the state to become a rural emergency hospital.
Critical access hospitals get paid by Medicare based on cost. If Nowata becomes a rural emergency facility, it would lose out on this benefit. Instead, it would get paid five percent above what larger hospitals receive for outpatient services, Miller said, which is typically less than what a critical access hospital is paid.
He added that, generally, nurses who work in the inpatient unit will often provide support for the emergency department because facilities may not have enough patients to dedicate a full-time nursing staff to it. These nurses would still be needed if inpatient services end, and Miller said this could increase the cost of emergency care because they would be serving a smaller patient volume.
"So, one of the challenges many hospitals have faced is, when they look at this, closing the inpatient services actually makes them worse off financially," Miller said.
The Center for Healthcare Quality and Payment Reform publishes a periodic brief showing how many rural hospitals are at risk of closing by state. It says the primary reason those hospitals are at risk is because private insurance plans are paying less than what it costs to deliver services to patients.
Hospital cost report data compiled by the organization show that services delivered to traditional Medicare and Medicaid patients within the last two years contributed positively to Ascension St. John Nowata's total margin. But services delivered to patients with private insurance and those who used charity care contributed negatively.
"It would make more sense to say they should be paying adequately for the care there rather than having the federal government simply give a grant to the hospital when we know that the problem is that they're being underpaid by private insurers," Miller said.
Dr. David Caughell is the president of Green Country Medical Inc. and a medical staff member at Ascension St. John Nowata. He's worked in town since 1988.
Caughell called this change "short-sighted." He said he wishes the hospital would invest in more services for Medicare patients so it could benefit from its current status as a critical access facility.
"If I had anything to say about 'Why this decision to REH?' is because it feels easy, and they don't have to come up with any capital to invest in the critical access format, even though you get a whole lot more back for this community," Caughell said.
Caughell said he worries about the hospital counting on the rural emergency model to attract patients.
"If you knew that they're going to just ship you somewhere if you're sick, are you going to stop in here, other than for your runny nose?" Caughell said. "I think people are smarter than that."
Caughell said he's watched the Nowata hospital shrink over the years, losing services like surgery and labor and delivery. Now, the 66-year-old worries about patients in need of recovery who won't come to Nowata if the hospital becomes a rural emergency facility.
"We're not going to be here for them. That's a bummer," Caughell said. "And what if it's me? I'm at that age. What if it is me?"
'I know what this hospital did for me'
Dozens of people filled the bleachers of the Nowata Middle School gym on a sweltering Sunday afternoon in mid-July for a rally hosted by Save Our Hospital. Speakers told of their knowledge about the rural emergency model based on hours of independent research. They also shared stories of how the hospital has impacted them and their families.
"Obviously, there are questions still unanswered, and one of the frustrating parts is we just don't know what to ask yet," said Terry Jordan, who was born and raised in Nowata. "Nobody told us about this starting to happen."
Kelly Parsons, a Save Our Hospital member living in Nowata County, said the group hasn't been able to meet with leaders at Ascension St. John in a public forum. The group is seeking transparency on the future of Nowata's hospital.
"Even if we do end up switching to the REH designation and we do lose our swing beds for a period of time, my hope is at least maybe we can be a jumping-off point or a good example of a city and a location that fought really hard to maybe even get the license back maybe in the future," Parsons said.
Joe Thornbrugh, who still relies on his wheelchair, couldn't make it to the event.
"I don't know what to do. I'm frustrated. … I can't go up and march and protest – because I would. I know what this hospital did for me," Joe said. "But I know other people can and will."
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