Lessons We Can Learn From The Challenges of Rural Healthcare

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By Genevieve Swenson

Rural healthcare has a number of systemic challenges, such as access to quality healthcare. Those challenges have been exacerbated by the pandemic. Some of the challenges are certainly more prevalent in rural areas but not unique to system wide issues in modern healthcare. As someone who lived and worked in the heartlands of this country, these sparsely populated towns have yielded valuable insights. I believe that the lessons learned from working in rural healthcare can be used to drive meaningful change in the primary care space across all geographies.

For many, rural brings to mind bucolic countrysides and pastoral farmlands. Interestingly, the US Census Bureau does not actually define rural but classifies Americans living rural if they do not live in an area defined as “urban” (an area with 50,000 or more people) or “urban cluster” (an area with at least 2500 people but fewer than 50,000). According to the Census Bureau approximately 61 million or 19% of Americans are classified as living  in rural areas. 

Below are four of the biggest challenges facing rural communities along with practical ways clinicians work to overcome them. 

Limited Resources Leads to Resourcefulness.

In a digital world, it’s hard to imagine waiting for anything. In rural areas, resources can be limited by fewer distributors that service an area. This can result in slower or delayed shipping times and price sensitivity. For example, labs and imaging are important diagnostic tools but in rural areas, it can take several days to get results.  While having limited resources is extremely challenging, it can also push clinicians to learn to be resourceful, innovative, and conscientious.   Clinicians must rely less on test results and focus on the patient story and presentation in front of them.  Procedures and SOPs should not inhibit our true value as clinicians. Challenging ourselves to become more resourceful, innovative, and conscientious across all healthcare entities would lead to less medical waste and spend. 

Bridge the Technical Divide with a Deeper Assessment.

Technology has become a staple in the delivery of healthcare.  The pandemic caused even the most resistant-to-change clinics and hospitals to reconsider their opposition to telehealth visits.  However, simply offering virtual visits to everyone, everywhere isn’t always possible.  Lack of reliable internet remains an enormous problem in many rural areas and even many people who live in urban and suburban areas can struggle to afford internet services.  

We need to continue to push for affordable, reliable internet access to be available everywhere.  Much of this must happen at the state and local levels.  But how can we as members of the healthcare team, work to use technology to its fullest capabilities whether we are in a rural or non-rural practice?  First, we must really know our patient’s situation.  Do they have reliable internet at home?  If not, how often can they access it?  What are some community resources with free internet access we could recommend to our patients like public libraries?  Consider if there are technology products in the marketplace that could benefit your patient(s) by increasing monitoring, touch points, communication, etc. that don’t rely on constant access to the internet.  Perhaps they store information and upload at a different time, or they come with built-in cellular service connections and don’t require use of the patient’s own internet.  Wanting to use the latest and greatest wearables and home monitoring equipment isn’t really very useful if we don’t first ensure that it is financially feasible and that the location they’ll be using it most can meet the minimum technology requirements. 

Transportation Problems Need New Solutions. 

Reliable transportation is an issue in rural America with lack of public transit and large geographical spread.  It can be time consuming and difficult to get back and forth to one appointment, let alone multiple follow-ups. Time constraints affect everyone.  So how do we take the issues of lack of transportation and time from our rural healthcare struggles and help to ensure that patients can follow through on the treatments we recommend and order?  We can start to focus and implement alternative care delivery models.  Telehealth options are vital but we should also be cognizant of training clinical staff on how to best give care through this modality as well as creating policies, procedures, and care guidelines; integration of the home monitoring devices into EMRs; and online communication tools including text and email are all great options in the technology space.  But taking a step back from the new technology approach is to also consider the benefits of in-home medical visits and pharmacy delivery. Nothing leads to more compliance than care that comes to the patient.

Staffing Models Struggle to Meet Patient Needs.

Primary care is becoming more and more difficult to staff across all markets, but especially in rural areas.  While nearly 20% of Americans live in rural areas, only about 11% of primary care physicians work in rural areas².  The healthcare system needs to be more open to accepting Nurse Practitioners and Physician Assistants and allowing them to practice to the full extent of their licensing and education.  You can see this readily in very rural clinics and EDs where NPs and PAs are sometimes the only clinician staffing the facility.  Overall, primary care NPs and PAs are much more likely to work in rural facilities at 28% and 25% respectively².  We need to learn to build and develop a partnership of mutual respect and support between physicians and NPs and PAs that helps to best grant access to care for patients as well as improves the care offered.  Full Practice Authority for NPs has been found to improve care quality and increase access to care³. The highest-ranking states in national health rankings are predominantly states with Full Practice Authority licensure for NPs, while states that restrict NP practice consistently rank in the lowest⁴.  

Primary care clinicians need more access to quick consults through virtual modalities to each other as well as specialists.  There are programs out there working to accomplish this.  Another type of staffing model involves a true integration of other clinician types into primary care such as physical therapy, pharmacy, and mental health.  This will create a population that is happier and healthier, lowering chronic disease, preventing acute and chronic issues, and lowering specialty referrals and imaging costs.

Rural healthcare has room for improvement, however, there are many learnings we can take from the struggles of rural healthcare settings to improve access, compliance, and cost of care across any geography.   

Genevieve Swenson is the co-founder and COO of Nice Healthcare, a company that is solving systemic pain points by bringing primary care directly to the patient with in-home visits, lab tests and x-rays.  It’s unique blend of innovation and personal touches is a welcomed disruption in modern medicine.

¹https://www.census.gov/content/dam/Census/library/publications/2019/acs/ACS_rural_handbook_2019_ch01.pdf

²https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html

³https://www.sciencedirect.com/science/article/abs/pii/S0167629617301972

^{4https://www.health affairs.org/doi/10.1377/forefront.20181211.872778/full/}