Almost 20 percent of America’s population lives in rural areas of the country, where accessing health care facilities and services can be challenging. The patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 residents, compared to 53.3 physicians in urban areas.

Rural hospitals work diligently to meet the health needs of the populations they serve, but they have long struggled with staffing shortages, inconsistent patient volumes, and financial instability.

Since 2005, 181 rural hospitals have stopped providing short-term, acute inpatient care, impacting their communities’ health outcomes, employment rates, and long-term population growth. While pandemic-related federal relief funds have helped to slow the rate of closure, this temporary assistance will soon come to an end.

In 2022, the Bipartisan Policy Center reported that 20 percent of the nation’s rural hospitals—441 out of 2,176—are currently facing three or more financial risk factors that put them at risk of service reduction or closure.

Several pieces of legislation are currently underway to shield rural hospitals from these financial pressures, including the American Hospital Association-supported Rural Hospital Support Act, which would address economies of scale for rural hospitals via the prospective payment system. The Save Rural Hospitals Act of 2021 would permanently suspend Medicare sequestration and extend Medicaid primary care payments for rural providers. The bill would also establish a national minimum area wage index to ensure rural hospitals are fairly reimbursed for their services by the federal government.

While rural hospital leadership is powerless to accelerate the passage of these bills, here are several steps they can take right now to strengthen their finances.

Understanding the need for two-way patient movement

As the pandemic has shown us, the ability of a health care ecosystem to expand and contract to accommodate surges in case volume is critical. Due to a lack of common infrastructure, our health care system is not well-equipped to match the right patients with the right resources at the best of times—which becomes problematic during a national health care crisis.

In rural communities, critical access hospitals and health clinics tend to transfer far more patients than necessary to regional facilities due in part to inconsistent patient assessment processes.

And instead of playing a limited role in the ecosystem, large receiving facilities tend to accept all patient transfers as the appropriate destination for only certain types of emergent care. This open-door policy has a ripple effect across the ecosystem, as it reduces the number of beds available for high-acuity patients.

This disconnect has its roots in how urban and rural hospitals handle scale. Urban facilities try to keep their average daily census (ADC), or the number of inpatients per day, at 95 percent or more of their overall capacity.

By contrast, the ADC of rural hospitals is frequently steady at 30 to 40 percent of their overall capacity, given changing service offerings and the population decline in rural areas. According to research, the median ADC (number of inpatients per day) in urban hospitals outnumbers ADC in rural hospitals by almost 15 to 1. Outside of a pandemic, rural hospitals rarely operate at capacity.

These available beds at rural hospitals can greatly benefit the health care system when capacity is at a premium. We must move beyond the one-way transfer of higher-acuity patients to larger hospitals that offer specialized care during widespread patient surges. We must also embrace the transfer of lower-acuity patients to smaller facilities. This two-way patient movement will help to right-size patient care across the ecosystem.

Implementing standardized assessment and decision-making

The first step to right-sizing care involves standardizing the patient assessment process. The patient’s acuity, or the severity of their condition, is the most crucial data informing the transfer decision. Assigning patients an easily understood, numerical acuity score gives care teams a quick shorthand that is helpful for making decisions throughout the episode of care.

Once care teams have assessed the patient, they need clear guidance regarding how to make transfer decisions. By specifying best practices for certain conditions, patient circumstances, and system and staffing constraints, rural hospitals can equip their staff to make fast, efficient choices to conserve resources, reduce risks, and deliver patients to the best care setting.

A strong patient movement workflow can help care teams address gaps in care and staff more efficiently—which can have a noticeable impact on revenue for hospitals with razor-thin margins.

Sharing patient movement data across facilities

The second step to right-sizing care centers on collecting, evaluating, and sharing patient movement data across facilities. By tracking data such as patient acuity, presumptive diagnosis, transport type, destination, and outcomes, rural hospitals will have greater insights into how patient movement functions for their organization. For example, they might uncover a need to develop a certain subspecialty in order to treat patients with a specific condition more rapidly. Over the long term, they might determine that stroke patients fare best when they are transferred to one particular regional facility rather than another.

In the short term, sharing patient movement data among sending facilities, transport vendors, and receiving facilities streamlines transfers, improving patient safety. For example, when clinicians are working with the same system, the patient’s acuity score helps care teams understand what care is required during transport; receiving hospitals can use that same score to inform bed placement for the incoming patient.

Creating mutually beneficial partnerships

Collaborative relationships between rural and regional facilities are essential to reducing inefficiencies across the care continuum. Across the country, the trend of greater collaboration around patient movement is growing. With a mutually beneficial partnership, an academic medical center might commit to receiving patients from five urgent care centers and three rural hospitals, while a specific rural hospital might commit to receiving lower-acuity patients plus a particular subspecialty.

Without a strong rural health care system, our nation’s ability to expand and contract with surges in demand will become very limited. When hospitals work together, they can better ensure that no community is left without a rural hospital for urgent care.

Richard Watson is an emergency medicine physician.

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