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There is ample evidence suggesting new solutions are needed in the way healthcare is delivered in rural America, according to Margaret Greenwood-Ericksen, MD, MPH, an emergency physician in the department of emergency medicine at the University of Michigan, who has been researching this subject.
“We know things are not going the way we want them to with rural health,” she says. “Health outcomes [in rural areas] are worse than they are in the general population, and rather than becoming healthier, like what we are seeing in some communities in urban areas, we are seeing rural populations stagnating, not getting healthier — and in some cases, with some conditions, we are actually seeing worse outcomes over time.”
Multiple factors likely play a role, including the fact that there is a significant shortage of both emergency and primary care providers in rural areas, says Greenwood-Ericksen, who notes that there also may be behavioral or cultural factors that keep patients in these regions from accessing the care they need.
“While it is hard to know which of those things is contributing to this, what is clear is that rural health is not headed in a good direction,” she says. In particular, Greenwood-Ericksen maintains that policies and models that work well in urban areas do not necessarily produce the same results in rural settings.
For instance, she explains that in an urban setting, you can put a clinic in a community that is struggling and see outcomes improve, but such an approach will not work in a rural area because the residents are spread across a large geographic area.
“Also, both populations have major social determinants of health that can really affect their health outcomes, but they are very different,” she observes. “Maybe there is an issue around affordable housing in a city, but for a rural area, housing may be [easily accessible] because it is not very expensive, but the area may have major issues with food insecurity.”
For all these reasons, healthcare delivery models must be tailored to the regions they serve, and Greenwood-Ericksen believes the prevailing focus, particularly among payers, on limiting ED use is not a good approach in many rural communities where access to care is a big issue.
“The problem in rural areas is it can be really challenging to get in to see a primary care provider, especially when there are not many available. And there are also not very many urgent care options,” she explains. “Emergency departments may be, for many people, one of the only accessible [facilities] in which they can get care.”
However, that doesn’t mean that there isn’t room for innovation in rural healthcare delivery. Greenwood-Ericksen favors the creation of a new model of care whereby both emergency and primary care providers work together at a central location where people are accustomed to accessing their care, and she has published her ideas on this concept.1
In fact, Greenwood-Ericksen notes that Carolinas HealthCare System has developed a model quite similar to what she describes in Anson County, NC, a sparsely populated region about 60 miles southeast of Charlotte.
“I think everyone is aware that in rural communities across the country, rural hospitals are closing,” explains Michael Lutes, president of the southeast division for Carolinas HealthCare System. “So what we really wanted to do was focus on a new model of care that was innovative and would truly improve the health status of Anson County.”
To do that, investigators looked at historic data and found that about 60% of ED visits at Anson County’s legacy facility could have been seen at a primary care provider’s office, Lutes explains.
“What would happen is [patients] would come to the ED and we would treat their emergent condition, but not the underlying chronic condition,” he says. “Then, three days later, the patients would be back because no one was managing their underlying chronic condition.”
Further, the region’s health outcomes simply were not what they should be under the old system, Lutes adds.
“That really challenged us to think about a different model,” he says.
Planners focused on designing an approach that would direct patients to the right care setting so that their underlying issues would be addressed, thereby breaking the cycle of repeated ED visits, Lutes observes. A lot was riding on the new approach, so to make sure the flow would work as intended, the healthcare system rented a warehouse and built a prototype facility out of cardboard.
“We had physicians, nurses, and all the different clinical staff building this new innovative model,” Lutes recalls. “I think we used 6,000 pounds of cardboard.”
All this prep work resulted in the healthcare system replacing Anson Community Hospital with a 43,000-square-foot facility that includes 15 inpatient beds and also a 24-hour ED that shares space with a medical home model.
The facility, which opened in 2012, today receives patients who present for care and receive a medical screening exam as required by the Emergency Medical Treatment and Labor Act. Exam results determine whether patients are directed to a primary care provider in the medical home or to an emergency provider. “We have criteria on what is appropriate to transition patients to an emergency provider or the medical home,” Lutes explains. “If they get transitioned to the medical home, it is not billed as an ED visit.”
Further, once patients are plugged into the medical home and receive subsequent appointments to see a primary care provider, they no longer need to undergo the medical screening exam. They have access to patient navigators who can help them negotiate the healthcare system and access necessary care.
While medical home patients and emergency patients are billed differently, they all are seen in the same space.
“On the right side of the department, the rooms are licensed to the medical home, and on the left side they are licensed to the ED,” Lutes notes. “And what we have done is actually built all the rooms to hospital code so that we can flex the rooms to accommodate patient needs.”
Early results suggest the approach is working as intended. “The first year we opened, we saw a 125% increase in primary care visits and we saw a 7% decrease in emergency visits,” Lutes observes. “We transitioned nearly 2,700 patients who came to the facility to the medical home who would have gone to the ED [if the medical home was not available].”
Today, the medical center sees about 16,000 emergency patients and 15,000 primary care patients per year, data that predict improved outcomes down the road, according to Lutes.
“We believe if we can transition 2,000 patients into a medical home each year, then the health outcomes [in the community] five years out will significantly increase because we will now be finally treating those chronic diseases, whereas before such patients would have just gone to the ED.”
In addition to providing a medical home to patients, the facility is equipped with a range of resources, including social workers, a pharmacy, an operating room, a lab, and a dedicated behavioral health area, Lutes explains.
“We have a community room that is focused on education because that is so important to improving outcomes,” he says.
Lutes adds that a range of specialty services, such as OB/GYN, general surgery, and pulmonary care, offer services through a satellite clinic located on the facility’s campus. Also, the center is hooked into the Carolinas HealthCare System’s vast telemedicine platform so that patients and providers can, when needed, connect with specialty consults virtually.
Regarding on-site providers, access to clinical staffing is a frequent barrier in rural parts of the country, and this was certainly the case in Anson County before the new medical center was built. However, the new facility has proven to be a lure to many experienced clinicians, Lutes observes.
“When we built this new facility and explained our commitment to improve the health outcomes and focus on health disparities in the community, we actually had people who were from Anson County but did not practice there want to come back and practice in the town they grew up in,” he shares. “We are fully staffed in our medical home, and, honestly, it is probably the first time we have been fully staffed in a number of years — since before opening the facility.” Further, most of the staff members are either from the community or live within 20 minutes of the facility, Lutes adds.
“They are excited about the things we are doing and our commitment to the community,” he says.
For instance, in the first three years of operation, the health system focused intensely on access and identifying healthcare needs, Lutes recalls. As part of this effort, the health system deployed a mobile unit into the community that could provide health screenings where they were most needed.
“We utilized heat maps to look for areas of the county that either had high ED utilization or patients that had not been in to see a doctor, and we knew they were eventually going to wind up in our ED,” Lutes notes.
The overall goal of this effort was to reduce the rate of the incidence of diseases such as cancer, obesity, and other chronic conditions. These are what Lutes refers to as lag indicators, and the health system expects to see improvements in the coming years. Creating a new healthcare delivery model always is challenging, but it does not have to be more expensive, Lutes observes. Indeed, he notes that the Carolinas HealthCare System built the Anson facility for a modest $20 million. While the facility is quite similar to what is referred to as a micro hospital, the intent behind it differs significantly, he explains.
“Oftentimes, micro hospitals are built in high-growth areas to meet a demand for extra beds,” Lutes says. “We built this as a model for how to improve the health outcomes in the community, not as a play to capture more market share.”
Lutes adds that the population hasn’t increased in Anson County in 50 years, so it is hardly a high-growth area.
Lutes acknowledges that the innovative facility would not have been possible without the expertise and resources of a large healthcare system, but at the same time it was equally important to work closely with the community and, in particular, local providers.
“They were excited because they realized that we needed to do something different, and that the traditional model wasn’t working in that community,” Lutes notes. “Overall, I think it has been well received.”
While Carolinas HealthCare certainly is thinking about using the Anson County delivery model in additional rural areas, other health systems have taken an interest in the approach, too. Eleven health systems from six different states have come to visit the facility.
“Just in the last week, I have heard from three different health systems who want to come tour our model,” Lutes says.
One thing that Greenwood-Ericksen finds exciting about the model in Anson County is that it links primary care providers with the ED in a central location where people are accustomed to accessing their care.
It also enables the healthcare system to potentially shift some higher-level costs associated with emergency care to a lower-cost billing structure. However, she notes that further innovations on the billing side would make it easier to deploy such approaches. “The payment structure is a big barrier to implementing these models,” she says.
In fact, some states are experimenting with the use of global budgets whereby payers give hospitals a set amount, and then the hospitals can transform the way they deliver care to what they think is best for the community.
“That removes some of these complicated concerns around costs and the fact that the ED is a more expensive setting,” Greenwood-Ericksen notes.
One problem is that while some healthcare delivery innovation is taking place in rural areas, information about these efforts often is not disseminated in the scientific literature, making it hard for other health systems to learn about new ideas that could work in their own settings, Greenwood-Ericksen says.
Also, luring emergency providers to work in rural communities remains a stubborn problem.
“I think a concern of emergency physicians working in a rural area is that they feel like they are going to be pretty unsupported,” she says. “By that, I mean that they feel as though they won’t have a lot of outpatient resources available to them.”
The model in Anson County addresses this issue by pairing emergency providers with primary care providers in the same space. “It assures emergency providers that they have adequate and appropriate outpatient access,” Greenwood-Ericksen says.
“I think the more you can provide resources for physicians and a sense that they are part of the community ... and that they are supported by both the hospital and the community, the more they are going to like their job and ... stay in it.”
Greenwood-Ericksen has engaged in discussions with some rural hospitals that are interested in redesigning their healthcare delivery process, and one of the things she always addresses in these conversations is what the obstacles are to making such a change. Communication is high on the list.
“There are different methods you can use to communicate, and they need to be tailored to the setting you are in, but that really involves getting your primary care providers together with your emergency medicine providers and having that conversation about what is going to work for people,” she advises. “It is really hard to line that communication up in an effective way, so it is a big issue, but I think electronic medical records will help with that.”
Another big barrier is resource availability. “Rural areas tend to have fewer resources available to them partly because less funding goes to rural areas and hospital margins are so much tighter,” Greenwood-Ericksen notes. “You may have some really good ideas for care delivery redesign, but you might not have the resources available.”
One possible way to get around a resource problem is to partner with other organizations in the community.
For example, some hospitals work with community partners to manage patients with substance use problems, but these pathways need to be developed, Greenwood-Ericksen observes.
Finally, with any large-scale change, one must find a way to pull all staff in the same direction. “Change is hard and no one likes it, even if you think it is going to make things ultimately better,” Greenwood-Erickson says. “It is hard to get everyone on board to agree to revolutionize the care you provide, so getting buy-in from your physicians and other providers is potentially a barrier, but also an opportunity.”
1. Greenwood-Ericksen MB, Tipirneni R, Abir M. An emergency medicine-primary care partnership to improve rural population health: Expanding the role of emergency medicine. Ann Emerg Med 2017;70:640-647.
Financial Disclosure: Author Melinda Young, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Margaret Leonard report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
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