Keeping care local mitigates physical access barriers, improves patient experience, and keeps revenue in local communities. The challenge: not all rural facilities are equipped to manage all clinical care. Best-in-class systems leverage robust telehealth capabilities and partnerships with clinical and non-clinical institutions to achieve the goal of keeping as much care local as possible while guaranteeing patients receive appropriate care.
Extending the reach of scarce resources: telehealth consults allow for scale of specialty care
Use of telehealth has skyrocketed since the onset of the Covid-19 pandemic, but prior to the pandemic, telehealth was already providing a lifeline to care – especially specialty care – for rural providers. Unit closures have increased alongside hospital closures in recent years, but best-in-class systems are able to take a principled approach to service rationalization that leverages telehealth to maintain or even improve – not reduce – patient access to care. Specialists can provide direct patient care or provider-to-provider consults, synchronously or asynchronously. Best-in-class systems also extend care protocols and standards across all system facilities, ensuring accountability for hitting quality standards and providing access to the resources needed to do so.
"People shouldn’t be penalized because they live in a rural community. We recognize it’s hard to sustain a
psychiatrist or rheumatologist in a small community. But if you can bring crisis care, cardiology, rheumatology, etc. to rural communities through telehealth, it improves access, enhances quality, and aligns care more closely with what they might receive in an urban setting"
- VP and COO, Specialty Based Care
"Everything we do, we do better because we’re part of Intermountain Healthcare. 10 years ago, cancer patients didn’t have access to chemo in our community. Tele-oncology has allowed patients to see world-class oncologists and receive treatments without the burden of travel. And Intermountain expects our quality outcomes to be just as good as any other Intermountain hospital.
- Administrator and CEO
Cassia Regional Hospital, Intermountain Healthcare
Meeting patients where they are: community-based services eliminate transportation and logistical barriers to improve pediatric access to care
Many rural patients face barriers to physically accessing care, such as long drive times, inclement weather, or unforgiving terrain. Best-in-class systems mitigate physical access barriers by bringing care and other services out into the community. Mobile clinics have become an increasingly popular tool to make it convenient for patients to access care, but they aren’t the only solution.
School-based health is a longstanding, demonstrated-effective method of improving access to care – predominantly primary care – for students. There are around 2,500 school-based clinics across the country, 35% of which are in rural areas.
Case study: Atrium’s school-based clinics improve pediatric access, reduce pediatric ED use
In Cleveland County, North Carolina, Atrium Health identified elevated rates of pediatric ED visits and a corresponding lack of pediatric primary care in the county. Working with the local schools, Atrium opened school-based virtual primary care clinics in 2017 to improve access to preventive care, reduce pediatric ED use, and increase in-school days. In its first four years, the program has seen a 90% student enrollment rate, thousands of virtual primary care visits, and a 40% reduction in ED use among enrolled students. The program is beginning to offer mental health services as part of the program in the 2021-2022 school year.
Hardwiring escalation processes: guarantee timely access to high-acuity care
While systems prioritize keeping care local, it’s imperative for rural hospitals to be able to safely escalate care when needed. Many rural hospitals, especially CAHs, aren’t equipped to manage the highest-acuity patients (e.g., major traumas or medical escalations). That’s not a commentary on the quality of services provided, contrary to common perception—it’s a function of the scope of services any given facility can sustain. Rural systems must have protocols in place to safely stabilize and transfer patients from local facilities to higher acuity care when clinically indicated.
"Being ‘best in class’ means being able to meet the needs of the community, including arranging for whatever services patients might need beyond what can be provided locally"
- Population health leader
Large system in the Southeast
For many providers, transfers involve a simple phone call from one facility to another to issue notice of transfer. But best-in-class systems, particularly those serving markets that are widely geographically dispersed or have major transportation challenges, look to impose more structure over transfer protocols to increase reliability. For example, UNM developed the Patient Access Line (PALS) to try and keep high-acuity patients local and to minimize the burden on small rural facilities of coordinating patient transport. Through PALS, rural providers are able to consult the flagship hospital for patients that may require emergency transport. The consultant can advise for immediate transport or recommend a course of treatment. The rural hospital will monitor the patient and ultimately make a joint decision with the consultant regarding whether or not the patient needs to be moved. PALS will then orchestrate transport, including air ambulance transport for patients located more than a few hours away from the flagship.
Rural health systems that can invest in air ambulance companies are able to facilitate nimbler and more reliable patient transfer regardless of geography.
Keeping patients —and dollars—close to home: backtransfers optimize patient experience and rural hospital financials
While transfers to higher-acuity sites of care are common and may be highly proceduralized, the reverse – moving patients back out to their communities when they no longer require the highest acuity level of care – is far less standardized or common. Clinically appropriate “backtransfers” can alleviate capacity constraints and improve throughput for flagship hospitals. They bring needed volumes and revenues to local communities. And they benefit patients by keeping them closer to home where the environment is more familiar and family members can more easily visit.
Unfortunately, backtransfers are logistically and financially challenging, and providers often aren’t set up to handle the complexity. Regulations around bed licensure can preclude hospitals from operating swing beds to allow for convalescence. And since DRGs are bundled and can’t easily be split across multiple facilities, backtransfers often involve revenue sacrifice on the part of the transferring facility. While this may work in one-off instances, it is not a sustainable model to scale.
Even the strongest rural provider systems tend to struggle in this area today. Overcoming these barriers will require payment and regulatory changes.
"You don’t keep the aging spouse of a farmer in a large metro hospital unless you need to – they need to be back in their community, in familiar surroundings where the RN taking care of them is likely someone they know and maybe even babysat 50 years ago."
- VP of Integration & Rural Health