The Heart of Rural Health Care
By Andrea Brewer
Prior to the onset of COVID-19, rural hospitals in the HRSA Vulnerable Rural Health Assistance Program were already accustomed to routinely “doing more with less.” When the pandemic struck, they were required to step up to an extraordinary level of service and patient care not previously encountered in their practices, adapting very quickly to strenuous and unprecedented clinical, staffing, and financial challenges. These hospital staff members faced the difficulties head-on with resourcefulness, determination, and a “can-do” attitude, working diligently to provide exceptional health care for patients in their communities.
The result is nothing short of extraordinary and is at the “heart of rural health care.”
Rural hospitals worked through numerous difficulties during the pandemic. They provided intensive levels of care for COVID patients while protecting their staff and non-COVID patients from the virus. Critical shortages of ventilators and medical equipment, protective personal equipment, and medication exacerbated the challenges, as did numerous personnel issues such as staffing shortages, exhaustion, and stress and fatigue from caring for critically ill and dying patients. There was no precedent for dealing with a crisis of this magnitude.
The financial impact of COVID has been particularly devastating for rural hospitals. Shelter-in-place orders combined with cancelled elective procedures seriously affected revenue streams, while funding from the Paycheck Protection Program and CARES Act was complicated by incomplete and sometimes conflicting guidance, resulting in hesitation to spend these funds. During this same period, rural hospitals were mandated to post detailed itemizations of their service and item costs online to implement the CMS pricing transparency initiative by January 1, 2021 deadline, putting further strain on their resources.
Rural hospitals were also forced to adapt to providing care for patients with higher acuity levels than they had previously seen due to tertiary hospitals being filled to capacity and unable to accept transfers, while simultaneously operating with often significant staffing shortages. Providing this new level of care often required clinical staff to stretch and expand their skill sets beyond their comfort level, resulting in them learning to use new types of equipment and perform procedures outside of their areas of expertise. A silver lining of COVID may be that these adjustments potentially enable hospitals to provide these services in the future.
Where capacity permitted, rural hospitals were in some cases able to leverage existing or forge new partnerships with larger facilities to care for COVID patients. One model saw tertiary hospitals focused on care for critically ill COVID patients requiring intensive care and ventilation; in turn, the rural facilities often accepted the larger hospitals’ overflow of less severely ill COVID cases and non-COVID patients. A second model employed the “clean/dirty hospital” concept, where all COVID patients were shipped to larger facilities, and convalescing and non-COVID chronic care patients received care at the rural hospitals.
Many hospitals had not used telehealth extensive prior to the pandemic, so they had to implement or expand telehealth programs very rapidly. Telehealth filled a void by providing routine health care for community residents fearful of exposure to COVID and specialty care for chronically ill patients that was not available locally. New legislation regarding telehealth policies and billing/coding procedures passed to facilitate telehealth utilization had to be navigated.
In the midst of second or third COVID surges this past winter, rural hospitals were tasked with developing a methodology to distribute and administer COVID vaccines within their communities on an aggressive timetable while dealing with the unpredictability of not knowing when shipments were scheduled or the number of doses to be received. This process was further complicated by vaccine guidelines that varied by state and were at times unclear or inconsistent.
Dealing with all of these issues forced hospitals to switch priorities, demonstrate agility, transform their hospital culture, and remain responsive to patient health care needs. The CORH team has had the privilege of engaging with the rural hospitals in our cohorts and listening firsthand to their stories, and we have been extremely impressed with the adaptability and resourcefulness they have exhibited. These staff members continue working tirelessly to meet the health care needs of their communities while navigating the challenges presented by COVID. These individuals truly represent “the heart of rural health care.”