Care Redesign

Care Redesign Survey: Lessons Learned from and for Rural Health

Insights Report · October 11, 2018

Analysis of the NEJM Catalyst Insights Council Survey on Care Redesign: Lessons Learned from and for Rural Health. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Amy Compton-Phillips and Namita Seth Mohta

More than 46 million Americans, accounting for 15% of the U.S. population, live in rural areas, according to the U.S. Census Bureau. NEJM Catalyst surveyed our Insights Council members to understand the similarities and disparities between health care in rural and urban/suburban settings, and to get a clearer picture of the barriers that exist in delivering excellent care to rural settings. Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic density and resource availability, each locale affords lessons for the other.

Our survey respondents have informed opinions — half report being personally involved in the delivery of health care in a rural setting, with an average of 12 years of experience. Just over 20% of respondents say they’ve been involved in rural care for more than 20 years. A large majority (78%) currently work at organizations that provide care in urban/suburban settings. (Survey respondents self-identified as working for rural or urban/suburban providers.)

Insights Council Members Have Substantial Experience Delivering Rural Health Care

From the Care Redesign Insights Report: Lessons Learned from and for Rural Health. Click To Enlarge.

Insights Council members say quality is superior in urban/suburban settings across all types of care. For primary care, rural settings are almost on par; a significant majority of respondents, 80%, consider primary care excellent, very good, or good in rural areas. But for specialty care, post-acute care, and mental and behavioral health services, the gap in perceived quality is wide and heavily in favor of urban/suburban settings.

In other aspects of care, however, rural areas do better than urban/suburban settings, according to survey respondents: 37% say the rural patient experience is superior, and 32% say the rural cost of care is lower.

Where rural health care quality falls shortest, say Insights Council members, is in mental and behavioral health services (including substance use disorders). Half of respondents say this care is poor or very poor. This is sadly supported by a 2017 Centers for Disease Control and Prevention report showing that rural counties consistently had higher suicide rates than metropolitan counties from 2001 to 2015. And drug overdose rates in rural areas surpassed the rates in urban areas in 2006, staying consistently higher since then.

Care design in rural settings could be better aligned with patient needs (as in urban/suburban settings as well). For instance, survey respondents don’t consider social determinants of health a significant barrier to excellent care in rural settings (listed by 23% compared to 40% in urban settings). Community Health Needs Assessments (CHNAs) — which are derived from patient and community input — say otherwise. In Alaska, the Southcentral Foundation, which provides services for the Native American population in the predominantly rural areas around Anchorage, redesigned services at the turn of the century based on findings from their CHNA, showing child abuse, child neglect, and substance abuse as the three areas most impactful to their communities’ health — all of which lead back to social determinants. In North Dakota, the top needs include resources to address diabetes and mental health/substance abuse.

Rural Health Care Is Rated Comparable or Worse Across Quadruple Aim Aspects

From the Care Redesign Insights Report: Lessons Learned from and for Rural Health. Click To Enlarge.

Rural health providers are responding to their needs by using telehealth. The biggest barrier to excellent care, according to the survey, is distance/travel time to facilities (tied with recruitment/retention of physicians). Expanded telehealth services are considered one of top means to improve care delivery in rural areas, tied with better access to specialty care, which can be delivered through telemedicine.

We asked respondents to tell us what would cause them to switch to practicing in a rural setting from an urban/suburban location. Many point to quality of life, less bureaucracy and more autonomy in decision-making about patient care, access to specialists via telehealth, and lower cost of living. “A desire to make a difference in a population that has many needs,” one clinician says. Others comment that usually the providers who grew up in a rural setting are the ones who want to return. What health care providers would likely give up from the urban setting, according to respondents, is higher pay, more opportunity for collaboration, and a faster-paced lifestyle.

To overcome the challenge of provider recruitment in rural areas, Providence St. Joseph Health (PSJH) has developed ways to allow physicians to have the best of both worlds: a base of operations in a more metropolitan area, while they deliver care to rural communities. PSJH also uses telehealth to give rural communities access to specialists and cutting-edge care — implementing the concept of moving knowledge, not people. In addition, to ensure a skilled workforce exists in each community, PSJH has leveraged our university to build distance learning programs for health professions students. The University of Providence can now train nurses, CRNAs, and techs close to their homes, so students can stay and work in the communities they’ll serve.

As rural and urban/suburban providers alike work to deliver outstanding care, they should ground health care system design in data and a deep understanding of the population’s needs. Broadening access to care, coordinating with services when socioeconomic needs trump health issues, building a skilled workforce dedicated to service in rural areas, and enhancing services that focus on mental and behavioral issues will be essential to creating thriving rural communities. To do otherwise jeopardizes the investment in care delivery and results in a system that is expensive and mismatched to the needs of the community it serves.


What would attract a clinician to change from an urban to rural setting?

“Being able to treat an entire community. Being the only game in town for both primary and basic specialty care. Working in smaller facilities and getting to know the staff and nurses. Being able to live in a rural setting.”
— Chief Medical Officer at a small nonprofit clinic in the Northeast

“Beauty of surroundings, different pace of work, stronger relationships to patients, ability to pursue livelihood in the mountains.”
— Director of a large for-profit physician organization in the West

“Sadly, $$$ 2) Awareness of the life style—even after learning of the advantages of rural practice, many physicians will prefer the urban but SOME would change to rural practice.”
— Executive at a small nonprofit teaching hospital in the Northeast


What would attract a clinician to change from a rural to urban setting?

“Being overwhelmed with call, and being truly the primary care physician (no one else is immediately available). [Spouse] wants to move. You want to earn more money.”
— Clinician at a small nonprofit physician organization in the Midwest

“Better quality of care with better specialty backup for patients, better school options, better social life options/entertainment.”
— Department chair at a midsized nonprofit hospital in the South

“Diversity in the types of diseases and patients that present themselves. Working in a larger group practice that is often the case in urban settings has the potential to provide more dedicated time away from the practice – shared call. Urban settings also offer non-healthcare related activities that are still available to rural clinicians but would require additional travel/time to participate.”
— Director of a large nonprofit hospital in the South

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about health care in urban/suburban and rural settings. The survey explores the type of settings in which organizations provide care, the quality of services provided, a comparison of aspects of care for rural versus urban/suburban settings, the biggest barriers to providing excellent care, and the tools, models, and policies to improve care delivery. Completed surveys from 730 respondents are included in the analysis.

The Barriers to Excellent Care Vary Widely Across Geographic Regions - both Rural Health Care and Urban Health Care

From the Care Redesign Insights Report: Lessons Learned from and for Rural Health. Click To Enlarge.

More than two-thirds of respondents say their organization provides care in an urban/suburban setting, compared with just over a third in rural settings. Looking at geographic regions of the United States, the largest share of respondents in the Midwest provide care in a rural setting (46%), while the Northeast has the lowest share (26%).

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

Download Full Report

NEJM Catalyst wishes to thank Allison Suttle, MD, Chief Medical Officer of Sanford Health, and Philip Polakoff, MD, MPH, MEnvSci, Consulting Professor, Stanford University School of Medicine, for their contributions to this survey. Check NEJM Catalyst for monthly Insights Reports not only on Care Redesign, but also on Patient Engagement, Leadership, and the New Marketplace.

Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.

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