AMERICANS in rural communities face many health disparities compared with those in urban or suburban communities. Death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke is more prevalent in rural communities than their urban and suburban counterparts. For example, deaths related to unintentional injuries are approximately 50% higher in rural areas. In general, these residents are older and sicker than those in urban or suburban areas of the US. Additionally, children with mental, developmental, and behavioral disorders face more community and family challenges in these areas.1
A lack of healthcare services has compounded concerns regarding the health disparities facing individuals living in rural areas of the US. This article discusses healthcare resources in rural communities and the role of telehealth services, nurses, and NPs in providing care to these patients.
Rural hospitals have been closing since the mid-1980s in the US. Between 1985 and 1988 alone, 145 rural hospitals closed, equivalent to about 5% of the total number that had existed in 1985. Additionally, 31 rural hospitals closed between 2008 and 2012, and 64 closed between 2013 and 2017. Approximately 50% of those that closed from 2013 to 2017 stopped providing any type of healthcare service. The other 50% continued to provide other types of healthcare services such as primary, outpatient, urgent, or emergency care, but this still limited inpatient care options.2
Many small rural hospital closures resulted from a change to Medicare's inpatient prospective payment system, which was originally created in 1983. The change was intended to control Medicare costs, but the result was that small rural hospitals experienced reimbursement and financial losses. Other factors also contributed to these closures; for example, fewer people requiring inpatient care due to changes in healthcare technology that have led to an increase in outpatient surgical procedures and services, increased competition from larger hospitals to attract those living in rural areas, and more transportation options that made accessing larger suburban and urban hospitals easier.2
In the author's experience, advances in technology, equipment, and diagnostic testing have increased exponentially and have added to expenses over the last decade. Small rural hospitals may not be able to afford this equipment, however, and subsequently divert these patients to larger hospitals.
Critical access hospitals and freestanding EDs
Recently, two types of facilities have increased to meet the needs of rural patients: critical access hospitals and stand-alone EDs. A critical access hospital (CAH) is a designation given to eligible rural healthcare facilities by the Centers for Medicare and Medicaid Services (CMS). Due to closures of many rural hospitals during the 1980s and early 1990s, the CAH designation was created in accordance with the Balanced Budget Act of 1997 to improve rural healthcare access by keeping essential services in these communities. New and existing CAHs have been supported by the Medicare Rural Hospital Flexibility Program, which was authorized in the Balanced Budget Act of 1997. CAHs must:3
- have 25 or fewer acute inpatient beds
- be located more than 35 miles from another hospital (or a 15-minute drive in areas with mountainous terrain or a 15-mile drive in areas where only secondary roads are available)
- provide around-the-clock emergency care services (using either on-site or on-call staff with specific response times)
- maintain an annual average length-of-stay of 96 hours or less for acute care patients.
Freestanding EDs exist in both urban and rural areas and have proved effective in improving healthcare access for those living in rural communities. There are two types of freestanding EDs: those affiliated with a larger facility and those that operate independently. As long as an off-campus ED is within 35 miles of the affiliated organization, it operates according to the same conditions of participation under Medicare. Those that are independently owned by individuals or groups rather than large hospitals are not recognized as EDs by CMS and, therefore, do not receive Medicare or Medicaid reimbursements for the technical component of their services.4 Currently, no federal regulations for freestanding EDs have been established; these EDs are regulated by individual states. A policy statement from the American College of Emergency Physicians (ACEP) offered recommendations for criteria that should be met by all freestanding EDs (see ACEP criteria for freestanding EDs).5
The number of off-campus EDs and independent freestanding emergency centers has grown in the past 10 years, with the Medicare Payment Advisory Commission reporting approximately 566 operational freestanding EDs. Of those, 64% were hospital-affiliated off-campus EDs and 36% were independent freestanding emergency centers.6
Telehealth has been growing as an effective method of delivering healthcare at a distance in the US. EDs and inpatient specialty consults that had been previously unavailable in these communities are now routinely available due to telehealth.7 Although this option has been helpful in increasing rural healthcare access, it is also fraught with challenges.
Broadband connectivity may represent a significant telehealth challenge due to poor internet connectivity in the rural US. Supervision of healthcare professionals using telehealth equipment, interstate licensure, data interoperability, and reimbursement are also major challenges.8 Despite these challenges, there is evidence of patient satisfaction with telehealth options. In one 2015 study, 95% of patients who participated in telehealth were very satisfied with the quality of care and rated it as better than or just as good as a traditional visit.9
As MDs age, the role for NPs expands
An aging population of rural physicians is another factor influencing healthcare access. According to data on physician age and location from the US Census, the number of rural physicians grew by 3% between 2000 and 2017, but the number of physicians under age 50 in these areas decreased by 25%. As the number of younger physicians entering rural practice has declined, more than 50% of rural physicians were 50 or older and more than 25% were 60 or older as of 2016. During this same time frame, the number of urban physicians under age 50 grew by 12%. By 2017, only 39% of urban physicians were 50 or older and just 18% were 60 or older.10
Although many initiatives have been launched to increase the physical workforce in rural areas, these have not been fruitful. By 2030, it is estimated that residents of rural areas of the US will have access to approximately 33% as many physicians per capita as their suburban and urban counterparts.10
One way to address growing patient demand and improve care delivery is the utilization of NPs in primary care settings. From 2008 to 2016, the presence of NPs in both rural and nonrural primary care practices increased. These healthcare professionals represented 25.2% of providers in rural practices and 23.0% in nonrural practices as of 2016, compared with just 17.6% and 15.9%, respectively, in 2008.11
Many studies have confirmed the high quality and cost-effectiveness of NP care, as well as a greater propensity to serve vulnerable populations such as rural communities.11 For example, one 2009 study found a high level of satisfaction with NP care in a sample of 211 young adults between ages 18 and 39 in two rural family practice offices. Overall satisfaction was correlated to patients who feel their provider is listening, have confidence and trust in their provider, and are involved with decision-making.12 In a secondary data analysis from the Consumer Assessment of Healthcare Providers and Systems, which compared communication and overall provider rating, NPs demonstrated significantly higher levels of patient satisfaction than other providers.13
These providers offer quality care to rural communities outside the US as well, with nurses and NPs finding solutions to limited healthcare services in these communities around the world. For example, NPs at rural urgent care centers in the United Kingdom demonstrated high levels of patient satisfaction.14 Another cross-sectional study found that NP community clinics provided accessible services to meet the needs of rural Australian patients with high patient satisfaction.15
In addition to improved patient satisfaction, NPs experience high job satisfaction. A 2017 study analyzed the 2012 National Sample Survey of Nurse Practitioners, which gathered data from 13,000 randomly selected licensed NPs and examined various aspects of practice in the US. According to the survey, NPs in rural areas were very satisfied with their work, highly engaged in primary care, and less likely to leave their position compared with their urban colleagues. Those in isolated rural areas also felt that they had greater autonomy than their urban colleagues.16
The screening and education provided by nurses and NPs in rural communities can help patients live healthier lives (see Screening and education).1 These clinicians also have an opportunity to become involved in research and policy making pertaining to rural healthcare in the US. The Rural Nurse Organization (www.rno.org/membership) provides members a voice in healthcare agencies, academia, government, continuing education, and access to resources to improve care for their patients.17
ACEP criteria for freestanding EDs
According to ACEP, these emergency care facilities should:
- be available to the public 24 hours a day, 7 days a week, 365 days per year
- be staffed by appropriately qualified emergency physicians
- have adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility
- be staffed at all times by an RN with a minimum requirement of current certification in advanced cardiovascular life support and pediatric advanced life support
- have policy agreements and procedures in place to provide effective and efficient transfer to a higher level of care if needed (cardiac catheterization labs, surgery, ICU)
- receive the same level of reimbursement for both the physician and technical component fee as a traditional hospital-based emergency department.
Used with permission from the American College of Emergency Physicians. Freestanding emergency departments. 2014. www.acep.org/patient-care/policy-statements/freestanding-emergency-departments.
Screening and education1
Nurses in rural healthcare settings offer health screenings and patient education such as:
- measuring BP and making optimal BP management a quality improvement goal
- teaching patients about cancer prevention and early detection
- encouraging physical activity and healthy eating to reduce obesity
- promoting smoking cessation
- identifying additional support for families of patients with mental, behavioral, or developmental disorders
- promoting motor vehicle safety
- advocating for patients regarding the safe prescription of opioids for pain management.
1. Centers for Disease Control and Prevention. About rural health. 2017. www.cdc.gov/ruralhealth/about.html
2. US Government Accountability Office. Rural hospital closures: number and characteristics of affected hospitals and contributing factors. 2018. www.gao.gov/assets/700/694125.pdf
3. Rural Health Information Hub. Critical access hospitals (CAHs). 2019. www.ruralhealthinfo.org/topics/critical-access-hospitals
4. Alexander AJ, Dark C. Freestanding emergency departments: what is their role in emergency care. Ann Emerg Med
5. American College of Emergency Physicians. Freestanding emergency departments. 2014. www.acep.org/patient-care/policy-statements/freestanding-emergency-departments
6. Medicare Payment Advisory Commission. Chapter 8: Stand-alone emergency departments. Report to the Congress: Medicare and the Health Care Delivery System. 2017. www.medpac.gov/docs/default-source/reports/jun17_ch8.pdf
7. Taylor L, Portnoy JM. Telemedicine for general pediatrics. Pediatr Ann
8. Weeks E. Medicalization of rural poverty: challenges for access. J Law Med Ethics
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15. Kelly J, Garvey D, Biro MA, Lee S. Managing medical service delivery gaps in a socially disadvantaged rural community: a nurse practitioner led clinic. Aust J Adv Nurs
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17. Rural Nurse Organization. Home. www.rno.org