Understanding Why Rural Health is in Trouble: Part II

A day in the life of a critical access hospital illuminates the various issues such facilities currently face.

EDITOR’S NOTE: This is the second installment in a three-part series about the daunting challenges currently faced by rural healthcare providers.

Rural hospitals are closing and reducing services at an alarming rate. In the first article of this series, some of the closure statistics were presented, along with additional information.

The challenges faced by all hospitals, but especially rural hospitals, are multifactorial – and not just financial in nature, but often due to lack of adequate reimbursement for services provided and egregious denial rates from commercial payors. One key factor is also staffing, nursing, and professional services shortages.

But the reasons go beyond staffing and reimbursement services. Some of the other challenges include the following:

• Difficulty in finding a physician, especially specialists such as those in cardiology, neurology, orthopedics, ophthalmology, and more;

• The need to transfer patients to higher levels of care for some of the above-mentioned specialties, reducing census numbers and the need to board these patients until a bed is available;

• Poor patient disease management and non-compliance that may be associated with low health literacy and perceptions of health – issues related to the Social Determinants of Health (SDoH);

• Inability to adequately respond to major trauma, except to stabilize for transfer to a higher level of care, and the availability the services to transfer;

• Frequent readmissions; and

• Lack of patient resources in rural areas.

Most of these will be covered in greater detail in Part III of this series.

We all are fairly well aware of what goes on in urban hospitals, but to totally understand what goes on daily in these rural hospitals requires realizing their challenges, especially with staffing. In addition, for critical access hospitals (CAHs) and Medicare patients, the average length of stay (LOS) may not be greater than 96 hours. Here is a rundown of those daily activities, specific to a three-day period in a CAH.

• Emergency Department – over a three-day period it averaged 12-17 patients each night, up until the early morning hours, with many of these patients being quite complex.
  • Some of those patients are boarders waiting for transfer to the proper floor or to a higher level of care (keep in mind that even though they are boarders, they must still receive care);
  • Some patients in need of critical care are just dropped off in the ED lobby;
  • Cardiac workup, hypoglycemic workup;
  • STEMI requiring intubation;
  • Social admits resulting from patients being unsafe for discharge, all the way to patients or families not wanting to leave;
  • Need for hospice care; and
  • Patient boarding with meningitis, falls – there is not enough staff to transfer them to the medical-surgical unit.

• OB – most of these hospitals do have OB units; otherwise, patients might need to travel 25-50 miles to deliver their babies.
  • There is still need for transfer for babies requiring NICU;
  • Generally, the hospital is aware of how many expectant mothers are due, but that is only if the mothers sought pre-natal care; and
  • Need for inductions.

• Medical-Surgical Units – since CAHs have a maximum census ability of 25, when the census is full, it results in boarders and the need for prompt discharges.
  • This does occur in urban hospitals also; it is not unique to CAHs;
  • Need for extra nurses to care for boarders in the ED if not enough discharges;
  • May need to care for critically ill patients waiting for transfer to higher level of care;
  • High number of patients detoxing from alcohol abuse;
  • Post-op patients, if appropriate surgeons are available, routine surgeries are taking place; and
  • Delays in specialty consults like cardiology and neurology that do not arrive timely from outlying hospitals or are only available certain days of the week, almost never on weekends.

As you can see, the challenges that rural hospitals face daily eventually can and do affect their survival in our ever-changing healthcare environment. This is why such hospitals are so necessary for the healthcare of their regions, and their presence must be preserved.