June 24, 2024

Serene Nest

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Taking A Holistic Approach To Rural Healthcare Sustainability

4 min read

Jason Povio is President and Chief Operating Officer for Eagle Telemedicine and an expert in healthcare operational excellence.

The statistics on the economic sustainability of rural hospitals continue to be grim. Since 2010, there have been 82 complete rural hospital closures and 66 converted closures. Converted hospitals are those that have eliminated in-patient care but remain open to provide other services like primary care or skilled nursing care.

These statistics reinforce the need for change from legacy approaches to healthcare in rural communities.

Statistics on rural healthcare regions are equally grim. The U.S. Government Accountability Office reports more than 60 million people—or one-fifth of the U.S. population—live in rural areas that generally have a population of less than 2,500. Rural residents are, on average, older and generally experience worse health, according to GAO, and face several challenges getting health care. The GAO notes a lack of housing for providers makes it difficult to recruit and retain professionals for rural communities. Other factors, the GAO says, are lack of insurance coverage and low reimbursement rates, contributing to rural hospital closures.

Rural communities, with low-density populations, can’t generate the revenue needed for a hospital to pay staff and operating costs and be independently sustainable. The answer to solving these challenges is adopting modern operational models and considering the interrelated factors that influence rural healthcare availability.

Economic Health And Quality Of Life

Mercer’s 2023 ranking of cities with the best quality of life for international employees is a good playbook for assessing a community’s ability to provide healthcare and a robust quality of life. It cites these factors: political stability, healthcare, education, infrastructure and socio-cultural environment. In North America, Vancouver made the top ten; San Francisco is the highest in the U.S. at 37 on the list.

Compare this to Ashland, PA, a town with a coal mining history, where Saint Catherine Medical Center Fountain Springs Hospital shut down in 2012. The town’s population has steadily declined to 2,471 as of the 2020 census. Almost 16% of the population is below the poverty line. To access high-quality care and specialty services, residents are an hour and a half to Allentown, PA, where the highly rated St. Luke’s campus offers specialty care.

Ashland’s declining population and changing economics have made it impossible to financially sustain a local 107 staffed-bed hospital.

Access And Advocacy

There are some encouraging signs of achieving better healthcare for rural, low-income and minority populations.

Both the U.S. Department of Health, and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), for instance, have launched sweeping initiatives to gather data, engage local agencies and organizations and identify and support specific actions to provide improved health equity:

• HHS uses its Healthy People 2030 framework to examine five key areas: health disparities, health equity, health literacy, well-being and social determinants of health.

• CMS has published a Framework for Health Equity to promote more synergies across the health care system and work to eliminate barriers to CMS-supported services and coverage.

Local communities and organizations can join the Healthy People 2030 framework and network with state and regional organizations to secure funding initiatives to expand health care services.

The National Rural Health Association (NRHA), an advocacy group supporting rural health initiatives, also sponsors several events around the country and offers an extensive list of resources and programs to advance equity.

Modern Operational Models

While there have been some positive developments, hospitals are still closing and the legacy models can no longer support the variety of primary and specialty care services rural populations need. That’s why we need alternatives to the legacy models. Here are a few to consider:

1. Team-Based Care

Team-based care relies on collaboration between healthcare professionals, social workers and community health workers to improve the delivery of healthcare by addressing the totality of a patient’s needs.


• Patient outcomes improve with better access to care and related services.

• More consistent management of chronic conditions.

• Behavioral health services and community agencies work with patients to encourage healthy living practices.


• Patients’ reluctance to see someone other than a physician to receive care.

• Efficient coordination across different team members and services.

• Billing has been traditionally physician- or provider-centric. A systematic reimbursement program must be in place to cover nurses or other professionals.

2. The Hub-and-Spoke Method

The hub-and-spoke method centralizes specialized services at the “hub” and provides less intensive care services at “spokes.”


• Better resource allocation. Physicians and staff at hub facilities can concentrate on specialty and intensive care.

• Specialty services generate more revenue.

• Spoke locations can shorten patient wait times for less urgent care.

• Patient outcomes improve.


• Designing a workable, efficient hub-and-spoke network.

• Being strategic in what spoke facilities to add with staffing and cost considerations.

• Establishing a clear structure and operating plan to cover care referrals, reporting, service protocols and a communication network.

• Avoiding overburdening providers and staff at any one location.

3. Telemedicine

Telemedicine alleviates physician and nursing shortages by adding telemedicine providers to expand care.


• Fills the gap in specialty and overnight care coverage.

• Hospitals retain specialty patients, adding revenue.

• Healthcare systems can expense telemedicine services over several facilities.

• Patients can receive care locally without expensive travel time.

• Round-the-clock in-hospital care is more readily available.

• Improved patient outcomes.


• Some physicians’ reluctance to practice telemedicine.

• Reimbursement complexity across regions.

• Sufficient broadband access in rural areas.

• Patient’s concerns about the quality of telemedicine screen consults.

A Holistic Answer

To achieve health equity, all the elements that contribute to a better quality of life must work together.

As communities and industries evolve, the challenges of lower income and access require a combination of innovative health care delivery models supported by government initiatives and local community advocacy. This holistic approach will nurture and support healthier communities.

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