Accessing Health Care in Rural America

Life in rural America has its advantages, with some remote communities perched in arguably the most beautiful landscapes in the U.S., from Alaska’s wild fringes and beneath Montana’s big sky to northern Minnesota’s lake country. But, where access to health care can be limited, living in less populous places isn’t for the faint of heart.

Doctor shortages — from primary care to obstetrics — hit wide-open places hardest. Less people means less patient demand for a host of medical services, though in some ways there’s more need per individual, as residents in rural communities tend to be older, on average, than those in urban centers.

Many who are starting families face challenges as well, since some rural hospitals have closed their labor and delivery units — like one in Grand Marais, Minnesota, in the state’s far northern reaches. “The closest place for the patients to deliver is Duluth, Minnesota, which is about 150 miles away,” says Dr. Paula Termuhlen, regional dean of the University of Minnesota Medical School Duluth campus. “Women could previously deliver in the community of Grand Marais.” Given the distance, she says, women have to relocate during their last trimester to safely be close to a hospital when they’re ready to deliver.

[See: 11 Ways Rural Life Is Hazardous to Your Health.]

From 2004 to 2014, more than 200 rural hospitals in the U.S. stopped providing obstetric services or closed entirely, according to the University of Minnesota Rural Health Research Center. And more than half of all rural counties nationwide now lack hospital obstetrical services.

Hospital closures have a birth (and even pre-birth, or prenatal) to death impact on care in a community, not only within the walls of the facility itself, but outside of the hospital, since frequently hospitals serve as health care hubs around which other outpatient services are offered.

To help address the issue, Texas A&M University was recently awarded a five-year grant totaling $4 million to fund its new Center for Optimizing Rural Health, which will serve as a technical advisory center to help rural communities throughout the U.S. maintain their hospitals or develop other means of accessing care when rural hospitals close. The $800,000-per-year grant comes from the Vulnerable Rural Hospitals Assistance Program, funded by the Health Resources & Services Administration, an agency of the U.S. Department of Health and Human Services.

The center will help communities in a strategic way, rather than plowing money into hospitals or affected communities. For example, Texas A&M has a program in south Texas that relies on community health care workers. “These are people who have — compared to doctors and nurses — relatively limited training, but they literally go into the homes of people with chronic disease” — people with diabetes, high blood pressure or congestive heart failure, says Dr. Nancy Dickey, director of the Center for Optimizing Rural Health and executive director of the A&M Rural & Community Health Institute, where the center is based. “Because they’re less costly to employ, they can spend more time with patients.” Community health workers provide patient education, which is having an impact. For example: “The program in south Texas has demonstrated remarkable improvement in diabetic control — how high their sugars are,” Dickey says. “And we know that if you can control the blood sugars, you reduce the complications and the hospitalizations.”

While house calls are ideal, experts stress that rural residents especially have to be proactive to access needed health care. It can help to organize community members to determine what the gaps are and to engage health care providers outside of the immediate area to address those.

[See: 10 Reasons to See a Physician Assistant.]

Standard recommendations also apply, like developing a relationship with a trusted health care provider — preferably a primary care provider, even if that means going outside the community to find one. But there’s added emphasis on the importance of maintaining those connections to stay up on preventive care and reduce the need for emergency care where there might not be a local hospital or ER.

Speaking of which, experts say it’s a good idea to have a plan when medical emergencies arise — as they sometimes do, even with ongoing preventive care. Know where you’ll go and how you’ll get there when time is precious. Dickey suggests thinking about these things not just from an individual, but a community, perspective. “Where is the nearest ambulance emergency services? What’s their average response? “And as a community, should you be providing some support — tax support or otherwise — to assure that if you don’t have a local site of care, you do have adequate emergency response,” Dickey says.

Of course the challenges in every community differ.

“Many of the communities we’ve worked with have developed something called health resource centers,” Dickey says. These could be located any number of places, from a designated space in a local drugstore to a fire station. But the idea is one-stop “shopping” where you can get information and help for everything from applying for health insurance to locating the nearest mental health services, Dickey says. “You can find out what social services are available in your community or the next community over, whether that’s food stamps or food pantries or Uber, Lyft, taxi or maybe even public transportation (if available) that would get you to the next community that offers local health care.”

In many cases, technology is helping to virtually bridge the distance in providing primary, specialized and mental health care via telemedicine. “One of the biggest shortages in the country, regardless of whether you’re in an urban setting or a rural setting or what’s called frontier setting — which is actually the smallest and most remote of our population centers — is access to mental health care,” Termuhlen says. “Telemedicine is ideally suited to be able to help individuals receive counseling of a variety of types, and then also to be able to provide support to the frontline physicians and advanced practice providers like nurse practitioners, doctors of nursing practice, physician assistants, who might be the ones providing that immediate care.”

In that way, using essentially just an internet connection and a monitor, you could connect with primary care doctor or a specialist, like a cardiologist or neurologist. “With a little more sophisticated technology, a physician can listen to your heart, look at an EKG, look in your ears and your eyes. About the only thing that’s hard to do without another health professional on the other end is actually feel your belly and put your hand on somebody. But you can see and hear most of what you would have done in an exam room,” Dickey says. “I think that that will be a huge portion of the answer for getting care to more isolated areas.”

Of course, broadband access still lags in less populous areas. “Internet access is tied to health in a variety of different ways,” Termuhlen notes. People are able to access health information online, or types of care not available locally through telemedicine. Not having broadband in an area can limit hospitals’ and hospital-affiliated clinics’ ability to fully integrate electronic health records and patients’ access to those EHRs, where patients could otherwise see test results, for example, and ask health providers questions to get timely answers through patient portals.

But access to broadband is improving, and cellphone service — though it also has gaps, particularly in wide-open places — has increased connectivity in rural areas. Smartphones can help with everything from a traditional phone call consult with a doctor (still possible, of course, with a landline, where those remain and cell service is spotty), or using a health-related app, or having a face-to-face consult over, say, FaceTime, which can supplement telemedicine that uses broadband and in-person doctor’s visits.

[See: Which Practitioner Do I See, and When?]

All things considered, experts say, there are significant challenges that one has to consider — especially if aging in place in a rural community or dealing with significant health issues. But for many, it’s possible to remain in those areas and ensure their health needs are met, relying on a primary care doctor, like a family medicine physician, to help coordinate care. That person can be like a beacon helping connect you to other health care providers and keep you healthy, “so that you can stay in that community and that communities can continue to thrive,” Termuhlen says. “Our campus is really proud to produce family medicine docs — particularly for rural Minnesota,” she adds, “because we’ve seen the success of that model.”

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