How rural healthcare can remain viable
Choice can be a double-edged sword—we all want more of it, but with too many choices paralysis can set in. Choosing a physician or hospital, for example, in an urban or suburban area without some kind of recommendation can truly be a daunting task.
But it beats having few or no choices. Increasingly, that’s the situation rural Americans find themselves in as the number of hospitals decreases and specialists stay in the cities.
While this may have been the trend in rural healthcare over the past 10 or 15 years, the current advance of technology in healthcare and the introduction of new care models offers rural hospitals much-needed opportunity. Heartland hospitals have the ability now to revamp and re-envision care in the essential areas where America produces energy and food.
What strategies and adaptions available now can ensure affordable and efficient rural care for the foreseeable future?
Strategy 1: Forge relationships. As with all hospitals, Winona Health (99 beds, Minnesota) had more than a few patients using the ER for chronic but manageable health conditions. To get ahead of and maybe prevent ER visits, Winona Health established relationships with organizations that included a nearby senior center, the state health department and Winona State University to provide support for the chronically ill. This led to the formation of the Community Care Network in 2012, through which Winona Health trained Winona State University students as health coaches.
By providing basic emotional support and performing a few tasks like grocery shopping, the Community Care Network reduced ER visits by 91 percent and hospital readmissions by 94 percent in the first 90 days of the program.
Are there organizations in your community that can contribute to managing the health of those who need support and preventing health emergencies in the ER?
Strategy 2: Innovate around care. Even where there are sufficient providers in a rural area, there are seldom enough specialists, which means patients sometimes have to travel long distances for specialized care. The University of New Mexico’s Project ECHO works to address this need through educational innovation by connecting specialists with physicians in rural areas, giving them the understanding they require to meet particular patient needs.
For more than 20 years, Stanford University has organized the Chronic Disease Self-Management Program (CDSMP). The program trains patients with chronic illnesses to manage their own emotions and behaviors—eating well, taking medications appropriately, communicating with friends and family, getting enough rest. Results demonstrate that the CDSMP improves the lives and satisfaction of chronically ill patients, and it saves money on reduced hospitalizations and readmissions.
Are there cost-saving care innovations your organization is not yet utilizing? How can you implement proven programs to keep costs down and bring patients deeper into the provision of care?
Strategy 3: Focus on what you do well. Most doctors willing to live in rural areas are not specialists.
“Specialty has a powerful effect on physician location choice …” according to a study on physicians and rural America published in the Western Journal of Medicine. “Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.”
Specialized care is not and probably never will be the strong suit of rural physicians. But this perceived weakness gives rural hospitals the opportunity to focus on natural strengths.
“A rural environment lends itself to population health and wellness,” says Jennifer Lundblad, CEO of Stratis Health, a Bloomington, Minnesota, nonprofit that promotes innovation and collaboration. “Providers probably know the patient and their family, they may go to church with them, they see them at the grocery store. If rural communities can figure out how to harness those assets, they will be well-positioned for the future.”
Of course, rural health providers remain the most important interface with patients, making them primarily responsible for creating access to specialists by forging relationships and innovating around care (above), and by maximizing the use of technology (below).
Are the wellness and population health efforts in your organization robust enough to create lead time when your patients have to utilize your relationships with specialists?
Strategy 4: Use technology. Much has been written about the potential of telehealth to alter the rural healthcare landscape.
In South Carolina, the state Department of Mental Health worked with the University of South Carolina School of Medicine and 18 hospitals, mostly rural, to provide telepsychiatry services. Most of the hospitals had no psychiatrist in the ER when mentally ill patients arrived, and the program provided that resource 16 hours a day, 7 days a week.
The telepsychiatry services have reduced both wait times in the ER and inpatient admissions, and it has lowered costs. Patients are going to their scheduled outpatient appointments more often, and levels of satisfaction are up for both patients and physicians.
Telehealth services, while not the only approach to technological innovation, are now seen as the most promising technical cure for what ails rural hospitals.
“There are two kinds of healthcare innovation: more-for-more and more-for-less,” write Nathan Washburn and Karen Brown in the Harvard Business Review. “The American healthcare system exemplifies the first kind, offering more and more value at higher and higher costs … Virtual consultations … are at the heart of a reconceptualization of rural hospitals (and eventually urban clinics and hospitals as well) because they provide access to higher-quality care at much lower costs.”
Of course, rural hospitals cannot provide effective population health and wellness services without effective, affordable, interoperable healthcare IT systems; the technology is a prerequisite. While rural health organizations currently lag behind their urban and suburban cousins in terms of adoption, government initiatives are helping to close the gap.
Is your organization maximizing affordable technologies, including telehealth and electronic health records, that improve the bottom line without busting the budget?
Strategy 5: Merge. Wafer-thin profit margins (if they exist at all) and threats of insolvency would cause any rural hospital executive to consider merging or being acquired. Predictably, activity in the hospital M and A sector has been brisk over the last several years as rural facilities sign on with larger, more financially stable urban and suburban health networks.
So, is independence even realistic, let alone desirable, for rural facilities? The answer is yes, though with caveats.
“The trick to staying local and ‘going it alone’ is often through configuring creative but limited partnerships with larger systems,” writes Beth Nelson in Hospitals and Health Networks. Complete independence may be completely historical, but that doesn’t mean rural hospitals can’t maintain a semblance of self-determination.
Have you explored the alliances available to you that may enable your hospital to survive and provide for the needs of the surrounding community?
A piece of good news: At least one study shows that rural hospital closures have not had a measurable impact on local mortality. The not-so-good news: rural residents are generally less healthy than urbanites, so having no local hospital and healthcare organization eliminates the opportunity to improve care through various wellness and population health programs.
Just as they always have, rural hospital executives and clinical leaders are doing all they can with the resources available. The difference in our current technological age is that so many more cost-saving tools exist than just ten years ago. By employing strategy and technology, rural healthcare organizations finally have the tools to move beyond survival and become catalysts for healthier communities.