Rural America is comprised of more than 61 million people (CMS, 2023). And the health and well-being of these communities rely on only 1,800 rural hospitals in the U.S. according to the American Hospital Association (2023). Rural healthcare and hospitals are essential components of the overall healthcare system. Not only because of the basic services provided across the continuum of care but because of the providers that make significant contributions to the well-being of the community. But the past several years have presented many challenges for rural hospitals due to reimbursement disparities, increased regulation, reduced patient volumes, and increases in uncompensated care, all of which can have significant implications for the financial viability of a rural healthcare organization and therefore the availability of healthcare services. According to Tulane University School of Public Health (2023), over the past 17 years, 124 rural healthcare facilities have closed their doors, and 80 facilities have been forced to reduce services. Yet another report published in 2020 revealed that over 400 rural hospitals are at risk of closing or are financially vulnerable (Tulane University, School of Public Health, 2023). Therefore, rural hospitals have been made to adapt by limiting services and adapting structure.
Several states have populations that are considerably more rural (see map below) including; Maine · 60.9%; Vermont · 60.6%; West Virginia · 50.7%; Mississippi · 49.9%; Montana · 43.7% (U.S. Census Bureau, 2020).
Rural communities differ across geographies, and often the focus revolves primarily around obstacles—higher incidences of poverty, intensified workforce shortages, older population, and technology challenges. The obstacles are very real, but rural providers agree that rural healthcare encompasses a range of healthcare activities aimed at promoting, maintaining, and restoring health to its residents, and often involves a combination of primary care, specialized care, emergency services, preventive measures, and community health initiatives that are tailored to the specific needs and challenges of these rural populations.
Rural healthcare differs from urban healthcare in several ways because of the unique characteristics and challenges of the rural population including:
- Accessibility: Rural areas often have limited healthcare infrastructure and services compared to urban areas. Residents in rural communities typically need to travel long distances to reach healthcare facilities, which can pose challenges in accessing timely care.
- Sociocultural Issues: Mental health and addictive disorders often go unaddressed in rural areas, due to cultural and social stigma that exists in these areas.
- Workforce and Provider Availability: Workforce shortages are often more difficult to mitigate in rural settings. Rural areas average 13 PCPs and 30 specialists per 100,000 people compared to 31.2 and 263 per 100,000, respectively, in non-rural areas, and 60% of federally designated health professional shortage areas are rural counties.Healthcare Facilities: Rural areas typically have a fewer number of healthcare facilities, including hospitals, clinics, and specialty centers, often with a limited range of services, limited resources and capacity, and limited advanced medical/healthcare technologies compared to urban facilities. Rural areas often lack nearby emergency departments and trauma centers, resulting in longer response times and posing increased risks during emergencies. Access to critical care and specialized emergency services can also be limited, impacting patient outcomes.
- Health Needs and Demographics: Rural populations often face distinct health challenges, and patients are, on average, older, poorer, sicker, have higher rates of chronic diseases such as obesity, heart disease, and diabetes, and have higher incidences of unmet social needs and substance abuse, leading to disparities in access to care. There may also be limited access to preventive care, health education, and different health risk factors compared to urban populations which all can contribute to health disparities.
- Resource Allocation and Funding: Resource allocation and funding for healthcare can differ between rural and urban areas and rural healthcare organizations often face greater challenges in securing adequate resources and funding to meet the needs of their communities. Rural hospitals often face financial strains and deficits, and rural populations represent less favorable payer mixes, when combined can cause limited access to quality healthcare.
- Socioeconomic Factors: Rural populations often face socioeconomic challenges, such as higher poverty rates, lower median incomes, and limited access to health insurance. These factors can contribute to decreased healthcare utilization, delays in seeking care, and challenges in affording medications or treatments.
- Technological Connectivity: Many rural areas have limited access to reliable internet connectivity which can impede the implementation of telemedicine services, electronic health records, and other digital health solutions that would otherwise improve access to care and remote consultations.
Overall, rural areas tend to have populations that are older and typically show a declining population but have less access to high-quality medical services and care. Understanding and addressing these differences is important for healthcare planning and the delivery of appropriate and equitable healthcare services in rural settings. Rural healthcare organizations aim to bridge the healthcare gap between rural and urban populations, and one shared common goal of all rural healthcare organizations is to ensure equitable access to quality healthcare services which means overcoming geographic barriers, workforce shortages, limited healthcare infrastructure, and socioeconomic factors that can impact health outcomes in rural communities.
Corazon believes it requires a tailored approach that considers the unique characteristics and challenges of the rural communities and involves initiatives to improve access to care by investing in healthcare infrastructure and leveraging technology to enhance healthcare delivery, recruit and retain healthcare professionals, and establish partnerships and networks.
Bridging the Gap
Access to healthcare is important for a multitude of reasons including overall physical, social, and mental health status, disease prevention, detection, treatment, and quality of life. Addressing the unique and challenging needs of rural populations requires collaborative efforts from policymakers, healthcare organizations, and communities to improve access to care, enhance workforce recruitment and retention, invest in infrastructure and technology, and tailor healthcare strategies. In Corazon’s experience, targeted efforts should first be focused on initiatives that expand healthcare infrastructure in order to expand or enhance access to care for rural populations.
To expand healthcare infrastructure, there first needs to be an evaluation of the existing infrastructure and an assessment of the current needs, including services provided and patient volume. This will assist in identifying the areas that require expansion or improvement according to community needs. In order to prepare for the future, prioritize resources, remain responsive to patient and community needs, and provide a clear and consistent organizational focus, a strategic plan should be developed. Corazon believes that creating a comprehensive plan, that outlines the goals, timeline, and resources needed for the expansion and consider factors like budget, available space, and regulatory requirements is a fundamental step to providing the foundation for the expansion of healthcare infrastructure. Having a strategic plan will increase the chances of successful and sustainable growth as well as assist in tracking progress toward goals. Some additional considerations that rural organization administrators should include are addressing transportation challenges, workforce shortages, how to leverage telemedicine and digital solutions, and if establishing partnerships and networks is an option.
Transportation Challenges: Rural areas often face transportation barriers due to limited public transportation infrastructure and low population density, road infrastructure, geographic isolation, and/ or distance to a healthcare facility making traveling a long distance necessary. The lack of nearby healthcare facilities increases the need for transportation to access medical services. Solutions may include a community transportation program or a partnership with a local transportation provider, implementing mobile clinics, or implementing/expanding telemedicine services. Mobile clinics, or “clinics on wheels” can be a viable solution to the transportation issues many rural communities face and can help improve access to healthcare. Additionally, infrastructure for mobile clinics is less costly, for both patients and providers.
Telemedicine and Digital Solutions: Another initiative to consider would be to leverage telemedicine and digital solutions. Telemedicine services can be particularly beneficial in rural areas with limited access to specialists. Investing in telehealth infrastructure can transform healthcare access beyond the physical facility in rural communities by increasing access to quality healthcare, increasing access to specialists, and shortening wait times for appointments. A telehealth program can provide rural patients with the ability to consult with healthcare professionals remotely, eliminating the need to travel long distances to see a specialist. Telemedicine also helps to bridge the gap between rural and urban areas by providing specialists in urban centers with the ability to remotely diagnose and treat patients in rural areas. Telemedicine improves the quality of care by providing access to the latest medical advancements and treatments. This allows rural hospitals to remain at the cutting edge of innovation while still providing quality care to their patients. Telemedicine can even help to reduce healthcare costs in rural communities by reducing the need for travel expenses and inpatient stays. Leveraging technology and telehealth solutions should be a priority for any rural healthcare organization, with an overall aim to implement electronic health records, telemedicine services, remote monitoring, and other digital health tools to improve access to specialized care, consultations, and health information for rural residents.
Workforce Challenges: Attracting and retaining healthcare professionals in rural areas can be challenging, but there are various initiatives that can be employed to attract healthcare professionals and providers. Research suggests that providers who train in rural areas and emphasize needed services for rural areas are more likely to remain and practice in rural areas (Tulane University School of Public Health, 2023). One initiative to consider would be to establish a rural specialty care residency rotation which could help ease the challenge of appealing to and attracting providers and specialists. Some other initiatives to attract and retain healthcare professionals and providers include incentives such as loan forgiveness programs and financial incentives such as housing assistance, professional development opportunities, or developing a recruitment partnership with an academic institution, professional organization, or regional healthcare network/system. This type of recruitment partnership can help identify and associate interested healthcare professionals with rural practices/facilities. Rural healthcare has many strengths and can be rewarding for those providers and clinicians who embrace rural living, including more continuity of care and personal relationships built between doctors and patients, and unique insight into the lives of their patients, all of which help them make the best possible treatment decisions for their patients (Clarkson, K. 2021).
Partnerships and Networks: The last strategic initiative to discuss which can help bridge the gap is to establish partnerships and networks by collaborating with regional hospitals/health systems and/or academic institutions and healthcare organizations. This type of partnership and collaboration can help to create a referral network, aid in the sharing of resources, leverage bargaining power to negotiate with payors and insurers to improve reimbursement rates, address the shortage of specialized services in rural areas, and improve patient outcomes. Another outcome of this type of partnership may result in improved infrastructure and an increase in specialized services in the rural area. Collaboration with larger institutions can result in lower costs, increased reach, improved performance and services, better recruiting and retention efforts for staff, and greater flexibility in payment models. Collaborations and partnerships with other healthcare facilities or organizations can result in shared resources, increased access to expertise, and best practices which can result in the overall improvement of healthcare delivery with the ability to offer a more comprehensive range of services. Collaboration and engagement with the local community is also crucial for rural healthcare organizations in order to actively involve community members in decision-making processes. This may involve collaborations with community leaders, and organizations, and conducting health education programs to promote wellness and preventive care. Ultimately the goal is to ensure that rural residents have access to a diverse range of healthcare resources without the need for extensive travel.
The specific initiatives developed may vary depending on the healthcare facility, its location, and the unique needs of the community it serves as each rural healthcare facility has its own unique challenges and opportunities. Corazon believes that by tailoring the approach to the specific needs of the rural community, healthcare infrastructure can be effectively expanded to improve access to quality care.
Implementing these initiatives can help rural healthcare organizations create an attractive environment for healthcare professionals and providers, encouraging them to choose rural organizations and contribute to the healthcare needs of underserved areas.
Meeting the Needs of Rural Communities
The 2020 pandemic led to an increased awareness of the barriers and disparities that face rural populations while resulting in an increased appeal for many to migrate to rural areas, bringing about support for improving rural health outcomes. Many rural health organizations have had to adapt in a number of ways to meet the needs of their communities by modifying services, implementing digital health solutions, or increasing the use of technology to deliver healthcare services online, meet the needs of more patients, and provide more specialized care. Challenges notwithstanding, rural providers and administrators need to be able to leverage resources, combat barriers to care delivery, and improve health infrastructure for all rural areas by developing a robust strategic plan and healthcare initiatives that can result in improving the quality of care. A robust rural healthcare system contributes to the economic development of rural communities. It attracts healthcare professionals, frequently the backbone of the communities they serve, creates job opportunities, and supports local businesses, leading to improved quality of life and sustainability in rural areas.
Overall, investing in rural healthcare is vital for ensuring equal access to healthcare services, promoting community well-being, reducing health disparities, and supporting rural development. To succeed in the face of major challenges in rural healthcare delivery, providers and administrators must find ways to overcome, innovate, and provide high-quality care to roughly 20% of the country living in rural settings (Rural Health Information Hub, 2023).
References
America’s Health Rankings analysis of U.S. Census Bureau, United Health Foundation, AmericasHealthRankings.org, accessed 2023 at: https://www.americashealthrankings.org/explore/measures/pct_rural/ME
American Hospital Association (AHA), Fast Facts on U.S. Hospitals, 2023. Accessed online at: https://www.aha.org/statistics/fast-facts-us-hospitals
Clarkson, K. February 2021. Blog: The Top 5 Challenges In Rural Healthcare – Part 5: Leveraging Strengths. Accessed online at: https://www.pulsara.com/blog/the-top-5-challenges-in-rural-healthcare-part-5-leveraging-strengths#:~:text=Rural%20healthcare%20has%20many%20strengths,treatment%20decisions%20for%20their%20patients .
Centers for Medicare & Medicaid Services (CMS), Rural Health (2023) accessed at: https://www.cms.gov/about-cms/agency-information/omh/health-equity-programs/rural-health
Rural Health Information Hub, 2023. Accessed online at: https://www.ruralhealthinfo.org/topics/healthcare-access#population-health
Tulane University School of Public Health (January 17, 2023) How to Improve Health Care in Rural Areas; Accessed online at: https://publichealth.tulane.edu/blog/how-to-improve-health-care-in-rural-areas/
Carol Wesley
Carol Wesley is a Vice President at Corazon, Inc. a national leader in program development for the Heart, Vascular, Neuroscience, Spine, and Orthopedic service lines, offering services in Consulting, Recruitment, Interim Management, and Accreditation. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach the author, email [email protected].
