The New Age of Rural Health Care
January 25th, 2016 by Lori Tobias
Maggie Elehwany, vice president for government affairs and advocacy for the National Rural Health Association, addresses attendees at a rally in Washington, D.C., in July. The March for Rural Hospitals included a 283-mile walk to the nation’s capital to draw attention to the need to save rural hospitals. Photo courtesy of National Rural Health Association

Maggie Elehwany, vice president for government affairs and advocacy for the National Rural Health Association, addresses attendees at a rally in Washington, D.C., in July. The March for Rural Hospitals included a 283-mile walk to the nation’s capital to draw attention to the need to save rural hospitals.
Photo courtesy of National Rural Health Association

Technology, grants and innovative programs allow smaller, remote doctors and clinics to offer a higher level of service

In 2002, Dr. Kevin Johnston had been on duty at Harney District Hospital in Burns, Oregon, only a month when a man in his mid-30s came in complaining of chest pain. He was admitted overnight and felt better by morning.

But the doctor was troubled.

“He had driven a long way, and I wasn’t sure he hadn’t had a blood clot,” Johnston says.

He took another X-ray and didn’t like what he saw—though he wasn’t sure what he was seeing, and no one was nearby to help figure it out.

What a difference 14 years makes. Technology, networking, grant programs, health care coaches and other innovative approaches are giving rural patients access to quality health care like never before.

As Johnston worried about his patient, he conferred with a specialist more than 100 miles away by phone.

Was it an aneurism, or a simple case of heartburn? There was no immediate way to be sure, so they decided to trust Johnston’s instincts.

The Bend hospital put a crew on standby and the helicopter flew in to pick up the patient. As it turned out, Johnston had been right, and the patient survived.

“If that gentleman came in today, I have a state-of-the-art scanner that I could scan him with,” Johnston says. “I’d call one transfer number and in one to two minutes they would be dispatching the aircraft, looking at the images and preparing to accept the patient.”

It is just one example of how dramatically rural health care has changed the last two decades.

Thanks in part to the Critical Access Hospital designation passed by Congress in 1997, the trend of rural communities losing their small hospitals at an alarming rate has been reversed.

Today, those hospitals—once cut off by time and distance from larger, urban facilities—are tapping into resources and tools that close the miles, eliminating guesswork and bringing services, specialists and technology to rural doorsteps.

“Twenty years ago, we didn’t have the Critical Access Hospital designation,” says Tom Morris, associate administrator for the Federal Office of Rural Health Policy. “The CAH designation was a sort of explicit recognition that if you wanted to have a small hospital survive, you had to take certain issues into consideration. CAHs very quickly grew from a couple of hundred in the 1990s to now 1,324 CAHs around the country. That’s out of about 2,000 rural hospitals total.”

Providing Personal Care
Federal grants provide funds for programs specifically for rural areas. An example is the Rural Health Care Services Outreach Grant Program that funded nurse case manager and community referral programs at St. Mary’s Hospital in Cottonwood and Clearwater Valley Hospital in Orofino, both in Idaho.

“What we wanted to do was take some of the folks who were the sickest and say, ‘How can we help you get better?’” says Pam McBride, chief grants officer at the two hospitals. “With the nurse case manager, you’ve got a nurse who calls or visits a patient on a regular basis. They have a lot more time to spend than a doctor would on a regular visit.”

That line of communication has saved lives.

“I can tell you that suicide is a particular problem for older males in rural areas because as you get older, you can’t do all the stuff that has made you so proud,” McBride says. “You can’t work quite as hard or you are retired, and you always identified with your job. It’s hard to find a focus and a purpose.”

All of the nurse case managers in the program have uncovered patients suffering deep depression and prevented suicide, McBride says.

One man had been under medical care for a long time. McBride says he had a good relationship with his doctor, was known in the community and had a spouse, yet no one knew he was hurting.

“He had multiple conditions,” McBride says. “The nurse case manager said, ‘Gosh, I am looking at what you are going through and this seems it would be really hard.’ Just having that one caring person in this environment where you weren’t rushed in time, it just opened the floodgates.

“That’s the secret with the program: You have people who can take the time to have the personal touch, which is what we’re so good at in rural communities.”

With the companion community referral program, the case manager ensures the patient has the means to get to the doctor, and has heat and food in their house. When those needs are not being met, they “close the loop and make the connection,” McBride says.

Telemedicine Fills Gaps
In Goldendale, Washington, grants have allowed Klickitat Valley Hospital to set up programs such as telepharmacy and teleradiology, with plans to expand to telestroke and teledermatology.
All of the programs work with cameras and computers, connecting doctors at the Goldendale hospital to specialists at other hospitals.

“We network with other providers,” says Jeff Teal, director of quality and risk. “There are certain systems that work with others. It’s not like telephone conferencing. It involves live interactive video. It is certainly more than Skype. In some cases, it involves close-ups. In some cases, access to medical records. There has to be a medical person on each end.”

The program is evolving, but telepharmacy and teleradiology have been used for years, enhancing the care the hospital can provide at the touch of a button, says Charis Weis, director of human resources and community outreach.

“It’s absolutely amazing,” she says. “It just takes the level of care to a whole new level.”

In the hospital pharmacy, a camera allows providers to consult with a pharmacist miles away. The pharmacist verifies the medication before it is dispensed.

“Telepharmacy in rural areas is critical,” Weis says. “We have to have a pharmacist, but we don’t have access to a pharmacist onsite who wants to work a limited amount of hours.”

Teledermatology will include a computer station with a high-resolution camera called a robot.

“It allows a dermatologist to look at the skin and make some preliminary decisions on the type of care that is needed,” Weis says. “The telestroke technology works in the same manner. The emergency room physician would be on the line with a specialist who would have eyes on the patient and be able to pick up physical signs of the stroke.”

In Alaska, where many rural communities can be reached only by air or sea, health care facilities are using telemedicine for supervisory purposes, says Gloria Burnett, director of the Alaska Center for Rural Health.

“You might have a behavioral health aide trained through the Alaska Native Health Consortium,” Burnett says. “They need to be supervised, but if you’re in a small village of 500 people, they don’t necessarily have the supervisory structure. So a lot is done via telemedicine where they connect through a telehealth network. It’s a money saver. We now rely on telemedicine for referrals.

“It’s much more in-depth than a Skype session. These are secure networks, making sure the quality is up to par, where the provider can see things and make a referral. A lot less money is being used to send a person in for care.”

Improving Record Access
Electronic health records also improve the quality of health care by allowing both patients and providers to readily review medical history, instructions and other information.
“In 2008, the American Recovery and Reinvestment Act gave a lot of incentive money to hospitals and clinics to expand to electronic health records,” says Brock Slabach, senior vice president with the National Rural Health Association, a nonprofit, membership organization. “Basically, it encourages providers to encourage patients to access records. It’s to provide more transparency so they have more control over their health care.”

Electronic records make it faster and easier to get a complete picture of a patient’s health, saving doctors time that can better be used to discuss questions, concerns and goals with the patient.

“I am working with a Down syndrome middle-aged woman,” says registered nurse Julie Church, a case manager at St. Mary’s clinic in Cottonwood. “Her mom passed away and she lives with her dad and brother. I realized recently she had not had any screening done. I was able to meet with two of her sisters. They escorted her in for the mammogram. She had a physical done. She had her annual labs done. She was updated on her vaccinations. It was really helpful to scan through medical records quickly and see what she needed to have done.”

Creating Partnerships
Networking is also pushing rural care in new directions.

“Collaboration today in health care is at the community level,” says Kevin Camp-bell, CEO of Greater Oregon Behavioral Health Inc. “We’ve moved away from an idea of competition between providers to the necessity of collaboration between providers to achieve better health, better care and lower cost. That paradigm shift, I think, is going to be in everybody’s best interest.

“Communities engaging in activities that promote wellness are going to have better outcomes than communities that depend only on the medical community. And healthy communities are places where people want to raise their kids.”

As a result, today providers are not nearly so alone—which is comforting to Johnston.

“There is no limit to what may come in the door: overdoses, heart attacks, broken bones,” says Johnston, the doctor from Burns, Oregon. “There’s nothing that won’t come see us first. We’re 130 miles from the closest center. We have to get that rapid information exchange so we can do what we do well.

“If someone broke an arm and showed up in Portland, there’s a good chance they will go to an orthopedist. Here, I am going to take a picture, call the orthopedist and say, ‘Will you look at the film with me?’ Let’s say I had to set the bone. I would take a second set of pictures and call and say, ‘This is the fracture. Does it look aligned? Do you think it will heal OK? How long should I leave on the cast?’

“Because I can get information to a specialist, I don’t have to send the patient on a 260-mile drive just for a few pieces of advice.”