The ability to provide rural residents with high-quality health care is contingent upon an adequate supply of providers. However, the shortage and maldistribution of physicians and other health care providers persists in rural America, despite ongoing federal and state efforts to increase the supply of providers practicing in these communities. In order to meet the needs of rural residents, hospitals and health systems must think innovatively about delivery models, community partnerships, telehealth, care teams and recruitment. Below are examples from the field on how rural hospitals and health systems are strategically and efficiently rethinking workforce planning and development to deliver high-quality care to their communities.
1. Increasing Residency Programs and Partnerships
Although there are approximately 80 primary care physicians (PCPs) per 100,000 people in the U.S., there are only 68 per 100,000 PCPs practicing in rural areas.i Rural Training Track (RTT) programs provide partnership opportunities for urban and rural hospitals and non-hospital clinical settings to promote rural training and to develop residency programs. Evidence shows that “…medical residents who train in rural settings are two to three times more likely to practice in a rural area; especially those who participate in rural training tracks.”1 Rural hospitals and clinical settings can obtain additional Medicare funding to train residents by adding residency slots to their cap by participating as the rural partner in a truly new RTT program. ii
The Accreditation Council for Graduate Medical Education approved a University of North Dakota (UND) residency in family medicine – the UND-Minot Program Rural Track Williston – in 2014. The program emphasizes rural family medicine training, exposure to individuals of diverse backgrounds and immersion in a community environment.
Columbia Memorial Hospital (CMH), Astoria, Ore., established a clinical affiliation with Oregon Health & Science University (OHSU), which provides a beneficial intersection of academic and rural medicine for patients in the Lower Columbia Region. To ensure program continuity and to offer a new learning experience, OHSU School of Medicine Emergency Medicine Residency Program established a unique rural emergency medicine rotation at CMH. Exposure to higher-acuity cases in the facility make it an ideal site for evidence-based clinical practice and education and puts students at the forefront of rural emergency medicine.
1 Patterson DG, Longenecker R, Schmitz D, Skillman SM, Doescher MP. Policy brief: training physicians for rural practice: capitalizing on local expertise to strengthen rural primary care. Collaboration of Rural Training Track Technical Assistance Program and WWAMI Rural Health Research Center; 2011.
2. Expanding the Care Team/Expanding Scope of Practice
Nurse practitioners (NPs) and physician assistants (PAs) provide substantial primary care in both rural and urban settings – in fact, NPs and PAs now account for 19 percent and 7 percent, respectively, of the primary care workforce .iii While the scope of practice varies from state to state, and between rural and urban settings, NPs and PAs are well-positioned to alleviate provider shortages in rural areas.iv
To manage increasing demand for primary care, hospitals and health systems must expand the size and scope of primary care teams, which is particularly beneficial for rural populations.v New models that allow for an increased role of NPs and PAs in the provision of primary care services, such as patient-centered medical homes emphasizing team-based care, have the potential to help address the projected shortage of PCPs.vi
To better meet the community’s need for primary care in its rural area, Lafayette Regional Health Center (LRHC) partnered with LiveWell Community Health Center and the Health Care Collaborative of Rural Missouri (HCC) and its four federally qualified health centers (FQHCs) to provide care while conserving scarce resources. All four HCC clinics are FQHCs and offer dental, behavioral health, primary care and social support services. The providers have expanded access, improved efficiency, enhanced the health of the population and maximized resource utilization by avoiding unnecessary duplication of services while directing patients toward the appropriate site of service.
To learn more on how LRHC expanded access points for primary care, click here.
3. ‘Growing Your Own’ Pathways
Studies have shown that PCPs are more likely to practice where they were trained. Rather than designing complex incentive packages to push recent medical graduates toward rural areas where they’ve never lived, according to a California Health Care Foundation report, experts today propose a much simpler and more effective approach: Train students already from underserved areas who will stay and practice in their home communities.
Avera Wagner Community Memorial Hospital (WCMH), Wagner, S.D., located 120 miles from the closest major tertiary hospital in Sioux Falls, identified a shortage of primary care providers in its 2013 Community Health Needs Assessment (CHNA) and noted that 11 of the last 12 physicians left within four years of initial employment. WCMH embarked on an ambitious “Grow Your Own” path to increase providers by recruiting hospital nurses to obtain an advanced degree and become certified nurse practitioners (NP-C). The success of homegrown NP-Cs has improved emergency department (ED) coverage and access to Avera e-Emergency, and eHospitalist allows NP-Cs to achieve the full potential of their license. WCMH-A is using advanced practice providers for 60 percent of ED call coverage, on the path to 80 percent. This has reduced direct ED costs by 25 percent. Inpatient satisfaction improved from the 33rd to the 99th percentile, and ED services improved from the 60th to the 93rd percentile while maintaining patient safety.
To learn more about WCMH’s efforts to ensure access to care for their community, click here.
4. Integrating Behavioral Health into Primary Care Settings
Integrating behavioral health into primary care settings is a common services integration model. Behavioral health integration can increase access to behavioral health services for rural residents, reduce the stigma associated with seeking these services and maximize resources. Nationally, the provider-to-population-ratio of psychiatrists and psychologists in non-metro counties is less than half the ratio than in metropolitan counties. Low behavioral health provider supply is most acute in non-core counties: 80 percent lacked a psychiatrist; 61 percent lacked a psychologist; and 91 percent lacked a psychiatric nurse practitioner.vii
Development of new workforce models include innovative types of allied Behavioral Health Aides (BHAs). Created to address behavioral health and substance use issues, the Behavioral Health Aide Program promotes healthy individuals, families and communities in rural Alaska where there is limited access to behavioral health care.viii
View the AHA’s resources on integrating physical and behavioral health to learn more.
5. Leveraging Telehealth Services
The availability of telehealth services in rural areas facilitates greater access to care by eliminating the need to travel long distances to see a qualified health care provider. Telehealth also can fill gaps in subspecialist care. Telepharmacy is another way to offer patients the convenience of remote drug therapy monitoring, authorization for prescriptions, patient counseling and monitoring patients’ compliance with prescriptions. With a nationwide shortage of psychiatrists, telepsychiatry can assist patients in need of behavioral health services who may otherwise have to drive hours to see mental health providers.
Grande Ronde Hospital and Clinics (GRH), La Grande, Ore., leveraged cutting-edge telehealth technology to improve the availability and quality of health care services for its patients through medical consults, direct specialty care, education and other services. In contrast to the traditional “hub and spoke” telehealth model, this critical access hospital developed a remote presence health care network, which connects patients to outpatient specialists. In the ED, specialty physician teams support GRH’s clinicians. Using robot technology telehospitalists and teleintensivists provide nightly call coverage and around the clock support services for onsite hospitalists.
For more resources on the benefits of telehealth for rural communities, click here.
John Supplitt is the senior director of AHA’s Constituency Programs and Elisa Arespacochaga is the vice president of AHA’s Physician Alliance and leads AHA’s workforce strategy.
i Petterson SM, Phillips RL, Jr., Bazemore AW, Koinis GT. [Accessed March 4, 2016];Unequal distribution of the U.S. primary care workforce. American Family Physician. 2013 87(11)
ii Cohen, A. Rural Training Track Programs: A Guide to the Medicare Requirements, Association of American Medical Colleges Health Care Affairs, 2015
iii Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood). 2013;32(1):11-19.
iv Larson EH, Andrilla CHA, Coulthard C, Spetz J. How Could Nurse Practitioners and Physician Assistants Be Deployed to Provide Rural Primary Care? Policy Brief #155. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, Mar 2016.
v Provider Scope of Practice: Expanding Non-Physician Providers’ Responsibilities Can Benefit Consumers, Research Brief #21, Altarum Healthcare Value Hub, November 2017.
vi U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Rockville, Maryland: U.S. Department of Health and Human Services, 2013.
vii C. Holly and A. Andrilla, Geographic Variation in the Supply of Selected Behavioral Health Providers, American Journal of Preventive Medicine, Volume 54, Issue 6, Supplement 3, June 2018, Pages S199-S207
viii S. Van Hecke, S. Behavioral Health Aids
A Promising Practice for Frontier Communities, National Center for Frontier Communities, Silver City, NM, August 2012.