Addressing the health of rural populations has been a challenge for Lexington Medical Center, a 438-bed hospital and system of 6,500 health care professionals in West Columbia, South Carolina, according to Robert Callis, MD, Medical Director for Quality and Population Health with Physician Network Services. Designing a system that targets the chronic disease, mental and behavioral health, and other specific needs of patients in rural areas has meant moving away from a more urban design.
For instance, two of Lexington Medical Center’s rural health clinics presently have an urgent care clinic. Primary care is being added with two nurse practitioners to each site. One additional nurse practitioner will cover acute care at each site. “We have a population with hypertension, diabetes, and other chronic conditions that are not well controlled by just being treated for acute problems,” Callis says. “If we’re going to improve health in these areas, we need more primary care.”
Respondents to our recent NEJM Catalyst Insights Council report, Care Redesign Survey: Lessons Learned from and for Rural Health, concur with Callis, ranking better access to primary care as the top tool / model / policy to improve care delivery. Nearly half of respondents agree that one of the biggest barriers to excellent care in the rural setting is physician recruitment and retention. Facing that same barrier, Lexington Medical Center has altered its primary care model and amplified the role of nurse practitioners. Callis, who is a family physician, says the abundance of evidence-based medicine for chronic diseases makes nurse practitioners well suited to manage these conditions, with oversight from a physician.
In addition, Lexington Medical Center partnered with South Carolina’s Office of Rural Health to implement patient-centered medical homes (PCMH) in the rural clinics. One of the major process improvements that came from PCMH is the scheduling of mammograms, colonoscopies, and other procedures at the time of a patient’s primary care appointment, which has increased compliance, Callis says.
Where the organization still struggles is in dealing with mental and behavioral health services. Lexington Medical Center wants to hire psychiatrists to work with primary care doctors and nurse practitioners. “Three psychiatrists have turned down the job because it is a new concept for the area. The psychiatrist would be a consultant and see few patients for long-term care,” he says.
Jon Wade, FACHE, CEO of Jersey Community Hospital, an independent health care organization serving a six-county area in Illinois, also is tackling recruitment to rural areas. “Twenty years ago, the family practitioner had a clinic and saw babies, parents, and grandparents, admitted patients to the ER, and delivered babies,” he says. Today, more providers are involved, including specialists, but rural settings “don’t have the volume of patients to keep them busy and to make the math on their pay work.”
So, Wade has innovated — knowing specialty services such as cardiology are important to rural areas — by partnering with other health care organizations. “Rather than having two or three full-time employees, we pay incrementally for a certain number of hours and a certain amount of productivity. They do the procedures that can be done in rural settings, with higher-level interventions coming to the hospital,” he says.
Wade also revamped how patients with opioid use were being screened in primary care. “Patients on pain medicine were being screened out because the physicians didn’t feel they had the resources to address their issues,” he says. “We had to add resources, including social workers, because those services are something the community needs.” The outcome: “[Primary care physicians] stopped avoiding those patients because they knew they now had an avenue to deal with that component of their care.”
The Waco Family Medicine Residency Program, which contributes 25% more family medicine physicians to rural areas than similarly-sized community programs in Texas, according to the program’s curriculum director, Burritt Hess, MD, has augmented their family medicine training over the past 7 years to include mental health and human behavior. Survey respondents call mental and behavioral health services in rural areas low quality. “We are graduating residents who are much better mental health providers than we were even 5 years ago,” says Hess.
The program also has returned to family medicine roots, offering residents training in a full scope of skills, including surgical, obstetrics/gynecology, critical care, ultrasounds, and more. “Family medicine is the discipline that can take someone from birth to death and provide almost 100% care,” Hess says. “It provides higher-value care in a more cost-effective way.”
“Every system has to develop their own definition of what is meant by ‘rural’ health,” says Neil Pickett, Vice President and Deputy Chief of Staff at Indiana University Health, a health system that operates seven critical access hospitals as well as an ambulatory/outpatient center in rural communities across Indiana. In Indiana, rural health is not the same as in Texas, he explains. “From Muncie to Jay County is about a half-hour drive, but it’s still rural.”
One option the health system is exploring in a preliminary manner is shuttling patients to more urban centers for care. “For some of these folks, the $10 to $20 in gas is significant, but, for the system, disrupting a specialist’s workflow to set up a clinic each week is expensive as well,” he says, adding more might be gained by bringing patients to the specialists. “Much more analysis about the cost/benefit” is necessary before such a program could be implemented, Pickett says.
Pickett and Indiana University Health are all-in on telehealth, listed among the top three tools/models/policies to improve care delivery. He acknowledges it’s not as easy as saying “let’s just set up telehealth.” Obstacles need to be overcome, including, “getting the physicians on board, trying to coordinate when specialists are available, and when patients want to be seen or can be seen.”
He emphasizes that those are tactics that can be resolved. “Telehealth as a strategy is key,” Pickett says.