Amidst the sweeping plains and endless farmland of rural America, residents face a pressing and pervasive problem. With providers so few and far between, patients face considerable difficulty accessing healthcare.
According to a leading advocate for improved rural healthcare access, the American Hospital Association, as many as 57 million Americans currently live in a rural area. These individuals face a litany of challenges, ranging from where they live to having enough doctors to provide care.
“Remote geographic location, small size, limited workforce, physician shortages and often constrained financial resources pose a unique set of challenges for rural hospitals,” AHA asserted in a recent rural healthcare resource.
The patient mix in rural regions also presents challenges, AHA noted. Patients living in rural areas are usually more reliant on public goods such as Medicare and Medicaid, leaving patients are more susceptible to public reimbursement changes.
What’s more, patients living in rural areas are also usually higher risk with a propensity to have complex health issues. Rural health specialists at Stanford Medicine state that patients living in remote regions are more likely to manage one of many health conditions:
- Being kept from working/daily activities because of physical or mental health
- Smoking and drug and alcohol use
- Chronic illness
According to Stanford Medicine research, rural populations also report poorer healthcare quality, with 4.5 percent of individuals rating their health as poor compared to 3.6 percent of their urban counterparts.
Improving rural patient healthcare access proves to be a multi-pronged effort. As individual healthcare providers and hospitals work to stretch their resources across rural regions, policymakers and industry leaders must give support to facilitate those efforts.
On a micro level, rural healthcare facilities must identify strategies to overcome staffing issues, close geographical barriers, and meet the social needs that affect rural patient health. And on a macro scale, industry players and policymakers must ensure that there are enough resources for providers to make these access fixes.
Rural hospitals address limited staffing issues
Rural areas are disproportionately affected by limited staffing issues. Stanford Medicine data reveals that these regions are home to about 20 percent of the nation’s patients but host only 10 percent of the nation’s clinicians.
In a May 2017 report, AHA recommended rural healthcare organizations reassess their inpatient and outpatient needs. Most rural areas have a tendency to dedicate a disproportionate share of their workforce to the inpatient side despite greater patient demand in the outpatient settings.
“Hospitals should start by engaging their boards in conversations related to the amount and type of services currently offered by the hospital to the community,” the report stated. “Then, hospitals should determine what services they should be providing based on the health needs of the community. This includes proactively fostering relationships with community organizations focused on improving the community's health.”
Healthcare organizations can also tap non-physician clinicians (e.g., physician assistants, nurse practitioners), the National Council of State Legislatures suggested in a 2013 report.
“Many states have taken steps to increase the procedures, treatments, actions, processes and authority that are permitted by law, regulation and licensure for non-physician primary care providers,” NCSL added.
Simply hiring non-physician clinicians is not enough, the council warned. Leveraging clinician skill sets judiciously is critical for increasing care quality and access efficiently.
States should look into the practice authority of nurse practitioners and physician assistants. In most cases, that authority should broaden in scope. Allowing more clinicians to deliver primary and chronic care will result in increased healthcare access.
Leveraging telehealth to overcome geographic barriers
Telehealth offers a technological bridge to connect patients and their clinicians, no matter the distance between the two parties.
“Traveling to receive services places burden on patients including cost and time,” says the Rural Health Information Hub. “For people with low incomes, no paid time off of their jobs, physical limitations, or acute conditions, these burdens can significantly affect their ability to access care.”
Telehealth can increase convenient care options while cutting patient costs resulting from travel time and transportation expenditures, according to researchers at the University of California–Davis.
A 2017 study found that telehealth produced about $100 in travel time cost savings per patient per year. In sum, telehealth reduced travel distances by 5 million miles across the entire study population, and resulted in $3 million saved in travel costs over a nine-year period.
Telehealth technology has also enabled rural hospitals to connect with healthcare experts that can deliver high-quality care to complex patients with urgent needs.
For example, the University of Mississippi Medical Center (UMMC) uses telehealth to expand its level-1 trauma center expertise to other rural hospitals throughout the state. Nurse practitioners in smaller remote hospitals complete regular training sessions to ensure top-notch quality of care and then connect with UMMC providers.
This strategy not only expands access to high-level care but also closes geographic barriers to patients. Patients no longer need to travel long distances to receive care from UMMC providers, and the end result is care access that is more convenient and timelier for patients in need.
Clinician training and seamless care quality are essential for telehealth success, according to experts from Hancock County Healthcare Access Initiative. The telehealth group from rural Georgia helped equip staff at the Community Health Systems Clinic in Sparta, Georgia, with telehealth kits to deliver care to remotely located patients. Residents can dial-in to receive nurse care from a mobile healthcare van.
“It’s a way to bring some healthcare to people who don’t often see it, but who do need it,” Dean of the Mercer University School of Medicine Jean Sumner, MD, said in an interview with mHealthIntelligence.com. Sumner is a seasoned rural healthcare expert, with nearly 25 years of experience in the field.
Success has come from educating patients and creating a new expectation that telehealth is an effective care delivery method. Additionally, project leaders strived to ensure quality as well as to ensure that technology does not replace quality.
However, telehealth does have its challenges, such as licensure and cost.
The Interstate Medical Licensure Compact (IMLC) seeks to overcome licensure barriers by creating a reciprocity framework that allows members to deliver telehealth care in different states. States with large rural resident populations, such as Nebraska, have signed on to the compact.
Telehealth also comes with some cost-related hurdles. While interested healthcare organizations will need to prioritize telehealth costs, grant funding options are available to certain entities.
Telehealth in rural areas also comes with a very specific challenge — access to adequate WiFi and broadband connectivity. Patients and clinics located in remote regions often do not have strong WiFi signals (if they have WiFi at all). Although arguably more efficient, broadband connections also have their limits in rural towns.
AMIA President and CEO Douglas B. Fridsma, MD, PhD, asserted that strong broadband access is a social determinant of health that must be addressed to create health equity in rural areas.
“AMIA believes that access to broadband is, or soon will be recognized as, a social determinant of health,” he wrote in a recent letter to the Federal Communications Commission.
Fridsma, along with representatives from AHA, called on the FCC to amend the Rural Health Care (RHC) plan to support better broadband for rural telehealth services. “Vulnerable groups face specific challenges related to inadequate access to affordable and consistent high-speed Internet,” he argued.
“Race, ethnic, and age disparities in patient portal use and readiness and preferences for using digital communication for health-related purposes have shown to be significant, and this, in turn, reduces their ability to participate in many new and exciting mHealth solutions,” Fridsma continued. “These groups would benefit from an environment that would foster a low-cost broadband option with access that would be open and as ubiquitous as possible.”
Fridsma recommended FCC partner with states to support broadband for opioid services, work with other federal agencies to assess broadband access in different rural communities, and align chronic care management programs with broadband needs.
Supporting alternative care sites to fill geography gaps
In addition to technology options, rural healthcare professionals should look to alternative care sites to fill geographic disparities.
As noted by AHA, rural communities see more outpatient needs than inpatient care needs. Ambulatory facilities tend to be less expensive to operate, have a smaller footprint, and are easier to maintain throughout rural areas.
“In some instances, a vulnerable rural or urban community may only need an access point for urgent medical conditions to be treated on an outpatient basis,” AHA explained.
To meet that need, urgent care centers and emergency medical centers (EMCs) could treat injuries or illnesses that appear non-life-threatening but require treatment within about 24 hours.
“EMCs provide emergency services (24 hours a day, 365 days a year) and transportation services,” AHA stated. “They also would provide outpatient services and post-acute care services, depending on a community’s needs.”
While challenges are certainly manifold when expanding the number of outpatient care centers in less populated regions, looking to creative care delivery solutions will be nonetheless helpful.
“Creating or expanding health centers in rural communities is a common strategy to improve access,” the National Council of State Legislatures wrote in that same 2013 report. “Many states support health centers through general fund appropriations or tobacco tax settlements.”
States can support health centers by providing funding, creating financial incentives for providers to practice in health centers, and developing incentives for payers to contract with health centers.
According to organizations such as NCSL, numerous types of health centers can fill care gaps in rural communities, including rural health clinics.
“The Rural Health Clinic (RHC) program aims to increase primary care services for Medicaid and Medicare patients in rural communities,” the organization wrote. “To qualify as a RHC, clinics must operate in a rural and designated shortage area and they must provide certain services and meet other requirements, such as employing a physician assistant or nurse practitioner.”
RHCs receive enhanced reimbursement for their services to Medicare and Medicaid patients. As of 2016, there were 4,134 across the country, the Kaiser Family Foundation reports.
School-based health centers also help deliver care to children. School-based health centers close care gaps for children living far away from traditional health clinics by offering primary care services, mental and behavioral healthcare, oral health, health education, and substance abuse counseling, among other services.
“Research suggests that SBHCs have positive effects on health outcomes—particularly for children with asthma and other chronic conditions—and on student achievement and attendance,” NCSL said. “Funding for the nation’s nearly 2,000 school health centers varies considerably, with many relying on a mix of public, private and non-profit funding.”
In 2011, states across the country allocated a total of $89.6 million to SBHCs.
Schools and healthcare providers who cannot partner in person can also tap into telehealth services. School-based telehealth allows pediatric patients to access healthcare using telehealth technology from within their schools.
Addressing social determinants of health
Outside of clinical initiatives, healthcare professionals in rural areas can also support their patients by addressing social determinants of health. Geographic barriers and treatment accessibility are two key social determinants of health capable of being addressed through community outreach.
“We determined that addressing these challenges through enhanced clinical-community linkages would aid community members in more effectively accessing available health care services, which would, in turn, improve their health outcomes,” the AHA said in a 2016 report on rural healthcare access.
Although each community is different with a varying set of needs and resources, they will likely follow a similar process for addressing these needs:
- Assess community needs using a community health needs assessment
- Take stoke of resources and partners available, ensuring all stakeholder goals align
- Engage all stakeholders through community partnership events
- Assess prior community outreach projects
- Create detailed action plan
- Obtain funding from appropriate benefactors, including community partners and grant providers
- Carry out intervention
- Periodically evaluate progress and make appropriate changes
Many rural communities have leveraged these partnerships to help improve better healthcare access. A collection of case studies published by Nebraska-based health system Bryan Health detailed innovative community programs that have helped deliver care to rural residents and close care gaps.
In the City of McCook, paramedics visit the homes of high-risk patients recently discharged from the hospital, for example. These paramedics are in charge of delivering some follow-up care to patients who would otherwise not be able to see their clinicians as well as conduct home checks to ensure patient environments are conducive to recovery.
The project was intended to close some of the geographic barriers patients in McCook face in accessing care. Like other case studies included in Bryan Health’s collection, the McCook project worked within the community to address a deep-seeded problem. The partnership with the fire department and paramedics created a proactive solution, rather than a reactive one.
McCook County Hospital serves nearly 30,000 patients, many of whom live outside of the city limits. The partnership has seen increasing success in closing geographic barriers, according to Bryan Health’s VP of Health Systems Services Carol Friesen, MPH, FHFMA.
“The common theme we saw through all of the stories is a shared purpose between partners,” Friesen pointed out in a previous interview. “They were invested in creating long-term solutions for the community, not just put a Band-Aid on it, but making a 20-year impact in the community.”
Other rural communities have worked to deliver mental healthcare in schools, closing a long-standing gap in behavioral healthcare access. And to drive better community wellness, rural hospitals have partnered with public offices to increase recreational fitness classes.
Ideally, supporting rural patient social needs will prevent the need for medical intervention. Creating a culture of wellness may eventually lead to less healthcare utilization and more ample resources to intervene during other medical issues.
How is the industry at large dealing with this issue?
The industry’s leading stakeholders also have an immense responsibility to create opportunities for rural communities to improve patient healthcare access. Industry leaders and policymakers must use nationwide programs and legislation to support individual interventions.
The American Medical Association has lent its support to the efforts by helping clinicians make decisions about where they plan to practice medicine, with the hope of reducing provider shortages in certain underserved geographies. The organization hosts an interactive digital map displaying physician shortages across the country with the goal of guiding doctors to these provider deserts.
"Improving patient access to quality care is a core mission of the AMA, and this mapping tool will show physicians and health care professionals precisely where their skills can most benefit populations in need," AMA President Andrew W. Gurman, MD, said in a statement.
AHA has also played a significant role in advocating for rural healthcare access, throwing its weight behind different legislative actions targeting patient care access.
Patients living in rural areas are disproportionately affected by regulatory and reimbursement changes to Medicare and Medicaid, the organization contends. Patients in these areas rely heavily on community health centers to access their healthcare conveniently and inexpensively. According to AHA, cuts in funding and reimbursement affect patient ability to access these centers.
AHA has taken up several advocacy positions to support patient access to public care options. The organization supported the Rural Emergency Acute Care Hospital (REACH) Act, which allows critical access hospitals (CAHs) and small rural hospitals with less than 50 beds to continue emergency and observation services but cease inpatient services. These facilities would still receive an enhanced reimbursement rate, allowing these hospitals to remain open.
AHA has also supported a bill that would extend the Conrad State 30 Waiver program, which allows state legislators to extend visa waivers for foreign clinicians to practice in federally-designated medically-underserved regions.
The organization has also backed several other pieces of legislation that would create exemptions for rural treatment facilities to optimize facility reimbursements. In doing so, these entities may have more revenue to remain open and serve rural residents. These acts include:
- The Rural Hospital Regulatory Relief Act of 2017
- The Rural Hospital Access Act of 2017
- The Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2017
- The Medicare Access to Rehabilitation Services Act of 2017
- The Telehealth Innovation and Improvement Act
These legislative and industry-wide efforts will be key to supplementing individual provider strategies for improving patient healthcare access. Rural communities are suffering from limited resources — not enough doctors, not enough money, and not enough clinics to meet geographic needs.
Healthcare professionals and practice leaders in rural areas must do their best to overcome those barriers to care. By reassessing staffing needs in practices, tapping into telehealth to overcome geographic limits, funding new care facilities, and addressing the social determinants of health, providers can improve patient care access.
And to make all of those individual efforts possible, policymakers and industry leaders must create more sweeping efforts. Passing laws supporting funding for smaller safety net facilities and directing clinicians to underserved regions will help individual hospitals support their patient populations.