By Miguel Burbano / Special to Healthcare Facilities Today

The Affordable Care Act (ACA) has significantly changed the healthcare landscape in many ways. Among these changes are the redistribution of health resources and services and the consolidation and repositioning of providers in the marketplace as consequences of the ACA’s emphasis shift from individual treatment toward population-based preventive care and wellness. The changes have affected all health organizations, but few have experienced a greater impact than rural hospitals and their communities. Consolidation has gained momentum and the development of comprehensive medical centers has concentrated specialty care in urban areas.

Created some 60 years ago, when post-war policies and programs sought to enhance the nation’s health and wellbeing, the 1946 Hill-Burton Act funded hospital and clinic projects in 4,000 U.S. communities — especially underserved rural communities — today, those rural hospitals are grappling with repurposing or replacing facilities that have reached the limits of functionality and use. They are also challenged by the migration of well-qualified primary, specialty care providers and skilled nurses to the cities. As a result, rural hospitals are increasingly referring critical and chronically ill patients to comprehensive urban medical centers.

Rural Health Organizations are responding to the new goal to provide “the best care at the best time in the right place for the right price,” which is not always possible in the local community. While referring out may be appropriate from the standpoints of quality, utilization and efficiency, it also creates practical and emotional consequences for vulnerable patients when they must travel farther for treatment.  

Solutions to these challenges affect all healthcare organizations — but especially rural district hospitals and rural clinics — and include development of a wellness umbrella, using innovative approaches to attract providers and nurses, and repurposing or replacing aging facilities.

The wellness umbrella

It is critically important to develop a wellness umbrella in local communities that covers the predominant population-health issues augmented with improved access for every member of the community to a Patient Centered Medical Home (PCMH). This not only will contribute to reducing the incidence of complex chronic health problems, it will also increase utilization of the local health system’s services. The inclusion of improved patient education, wellness and fitness programs invites patients to become more aware and more involved in managing their health.  

While physical access (beyond appointment availability) to local clinics and hospitals can be increased with improved local transportation, access can also be increased by leveraging technology. For example, the use of digital communication technology and diagnostic telemedicine enables rural clinics and hospitals to leverage their own resources and the knowledge of specialists available in urban medical centers. The economic savings are evident yet reimbursement remains challenging. Payments for group visits and tele-consults require further development.

The number of local access points can also be significantly increased by leveraging changes in state regulations that allow pharmacists, certified registered nurse practitioners and nurses in care centers and walk-in clinics to provide many of the same basic healthcare services as traditional office-based medical providers.

Among the key considerations enabling the wellness umbrella is achieving the optimal balance among several variables, including patient empowerment and participation, as well as the health-wellness organization’s care protocols for coordination. Involving the patient/customer in the specific care and wellness protocols is essential. 

Innovative ways to attract well-qualified providers

While there is debate as to whether the U.S. has sufficient numbers of well-qualified primary and specialty care providers and skilled nurses, the redistribution of services, consolidation and repositioning is concentrating and rewarding “super-providers” and large organizations in urban settings. Acute centers also agglomerate medical providers, contributing to the rural void. Increasingly, providers who are recruited overseas fill the staffing gaps in rural settings. This transition often is accompanied by unanticipated cultural, language and communication barriers. In particular, there is an acute shortage of primary care providers in remote communities, especially in those that are perceived as less desirable work/live environments. From a care continuum perspective, unfortunately, every time the rural patient goes down the highway to the city seeking specialists’ care, the local hospital loses dollars, with a predictable impact on the local economy.

Rural healthcare systems are becoming innovative in attracting talent to their communities with upscale short-term housing, provision of transportation and specialized spaces for providers to treat patients.  For example, Neenan has a client whose master plan includes initially 12 (and eventually 24) new residential housing units adjacent to its hospital for visiting providers for 2- to 3-night stays; these studio, one-bedroom and two-bedroom apartments offer first-class accommodations and amenities, including fitness centers, swimming pools, outdoor living space and walking trails. The organization is aiming to open the doors early in 2017.

Innovators are also providing transportation as a method to optimize providers’ travel time (including aircraft to bring individual providers and teams to the local community), expanding contact work time, rather than spending a day behind the wheel of their cars. As a result, specialists are able to contribute a full, efficient day to the rural hospital.

Health and wellness organizations are also creating, repurposing or reallocating space, not only based on average utilization demand, but on the availability of resources. For example, in order to satisfy the needs of a surgeon who visits the rural hospital for one day each month, the hospital may need to build two operating rooms — meeting scheduled utilization and not statistical average demand. 

Rural hospitals can avoid customized spaces for visiting specialists by employing flexible design strategies that include appropriate, standardized universal examining rooms, which support multiple medical equipment deployment. These flex spaces, or points of care, also can be used by the local providers. Rural health systems are also differentiating themselves and attracting top talent by developing new state-of-the art buildings and procedure rooms (especially operating rooms) and by deploying new technology and instrumentation, such as robotic surgery systems.

Alternative financing of rural facility projects

The crisis in healthcare has also coincided with aging plant. Fortunately, there are affordable alternatives to traditional financing mechanisms available to rural health systems, including federal programs that are tailored to stimulate smaller, local economies. The U.S. Department of Agriculture (USDA) Direct Loan & Grant Program (http://www.rd.usda.gov/programs-services/community-facilities-direct-loan-grant-program) offers an interest rate below 4%. The U.S. Department of the Treasury Community Development Financial Institutions Fund’s New Markets Tax Credit Program provides tax credits that attract private investment to economically disadvantaged communities. Recent examples from Neenan’s portfolio include the Columbia Basin Health Association’s Othello Family Clinic in Othello, Wash., and Northern Nevada HOPES Community Health and Wellness Center in Reno, Nev., which were funded by the New Markets Tax Credit; and Hazen Memorial Hospital Association’s Sakakawea Medical Center in Hazen, N.D., which was funded by a USDA loan. It is also much easier to finance a project in a popular, recognized community — even if it is rural — compared with a project in a remote, relatively inaccessible community that is not growing. 

A new type of medical facility is needed that is more flexible and appropriate for the rural setting that the traditional definition of the rural hospital — more like a combined urgent care/surgical center “on steroids.” While the ACA urges a shift from the inpatient to the outpatient setting for many procedures, the challenge remains, to receive a hospital reimbursement rate, an outpatient facility still must meet hospital standards. Success stories from Neenan’s portfolio include the Middle Park Medical Center, an urgent care/surgical center in Granby, Colo. 

What is the best solution or combination of solutions?

There are several fundamental components of a decision-making process to reposition an organization in a changing healthcare landscape. Making real, metrics-grounded assessments of the health system’s unique market position is critically important; no solution is universally applicable. Validating the ultimate purpose of the organization — is its primary goal to increase revenue or to create wellness, and how can it fairly reward contributions to achieving its primary goal? — is equally important.

Effective long-term population-based planning is another component. This process has barely begun, and the industry as a whole and individual healthcare organizations need to develop expertise and skills to address this new challenge and accelerate the pace of change. It has been known for quite some time that certain dietary and behavioral habits contribute to the development of chronic illness; healthcare must intervene earlier to prevent such outcomes.

The industry as a whole and individual healthcare organizations also must encourage and embrace the development of new information, diagnostic and treatment technologies to improve access and outcomes and to reduce costs. 

It is evident that the healthcare industry is making progress in its transformation to population-based health and wellness. Rural health systems, such as the innovators described above, are demonstrating that they can provide “the best care at the best time in the right place for the right price,” continuing to fulfill the noble intention that marked their creation some 60 years ago. 

Miguel Burbano de Lara, AIA, NCARB, is senior vice president with The Neenan Company and can be reached at miguel.burbano@neenan.com.