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  • Writer's pictureericjcarrig

Solving the rural hospital dilemma to address an aging population, poverty, and isolation

How do we take on the facts that health tends to be worse and demand for mental health services and the suicide rate are rising in rural communities?



The core healthcare challenges in rural communities are transportation because people have to travel to get care and many senior citizens can no longer drive, social isolation, the availability of specialized services, and the financial viability of rural hospitals.


I spoke with Tyler Malone, a research Investigator for the North Carolina Rural Health Research Program in the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill about how to address these problems by enhancing rural hospitals.


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The risk of living in a rural community


Rural communities can be diverse ethnically and culturally, but they all tend to be older, poorer, and isolated. Therefore, health tends to be worse than in suburban and some urban areas.


Also, demand for mental health services is rising in rural areas along with the suicide rate. It seems like social isolation and limited economic opportunity are to blame.


The core healthcare challenges in rural communities are transportation because people have to travel to get care and many senior citizens can no longer drive, the availability of specialized services, and the financial viability of rural hospitals.


Solutions to revolve around the future of rural hospitals

Many rural hospitals are facing insufficient demand for their services and capabilities to generate enough revenue to cover their fixed costs. Further, many rural residents are poor. Medicaid does not pay hospitals well, and without it people can’t pay for care in the first place.

The risk of hospital closings is that people with complicated situations and/or who must be treated immediately can’t get care.


Complicating things is that many people “bypass” their rural hospital, believing that going to a suburban or urban facility is better. Bypassing rural hospitals threatens their viability because they miss out on revenue they otherwise might have received.

The research community hypothesizes that people may believe that urban hospitals are better than rural hospitals, because they hear about newer facilities and equipment and nice cafeterias.


The reality is that rural hospitals are as good or better than suburban and urban hospitals when comparing outcomes of routine procedures.


However, suburban and urban hospitals typically perform better in specialized services because the volume of cases gives clinicians more experience treating a wider variety of conditions and complications.


So when there is a greater risk of post-surgical complications, as there often is with lower-income and older people, it makes sense to go to a hospital where the doctors have seen a wider variety of situations.


Still, even if people have to visit a hospital that is far away to take care of an urgent need, they may not return for follow-up visits because they lack transportation, or it is simply too far. Putting off care can lead to complications, which then puts people back in the position of needing urgent care.


To help people make informed decisions before traveling to a distant hospital, an organization called The Leapfrog Group provides the availability of different services and outcomes associated with them at specific hospitals.


Another risk of rural hospitals closing is that they are often the largest employers in small towns. When they close people leave, increasing isolation and lack of access to care for those who remain. Economic conditions get even worse after years of decline brought on by the departure and closure of manufacturing and distribution operations over the last 50 years.


What’s left would be chain retail stores, restaurants, and organizations that cater to old and low-income people.

Combined, figuring out the most appropriate services for rural hospitals to provide to serve the community and remain financially viable is critical.


Solving the rural care dilemma


Where Medicaid covers a broad enough population, it can allow more people to access care. That would drive demand for services, which would increase the viability of local hospitals.


Still, the underlying problems are still age, isolation, low incomes and poverty, and transportation.

Some Staes are exploring rural emergency hospitals (REH), which would have fewer than 50 beds, only focus on emergency and outpatient services, and not offer inpatient services.

These types of hospitals wold provide services that need to be delivered right away. People would have to go further away for hospital stays. The catch is that hospitalization may also be required immediately.

The questions become how people will be transported in a reasonable amount of time and what capacity of inpatient services in rural hospitals is required.

Rural communities have a history of applying their own solutions to local problems, so many rural communities want to figure this out by themselves.

For example, New Growth Transit is an example of addressing the transportation challenges of rural communities. New Growth Transit, a Missouri organization comprised of a volunteer network of local drivers, takes people with mobility challenges to healthcare facilities that are further away and with getting to grocery shopping and local doctors appointments.


A services like Mental Health GPS might also be valuable to rural communities. It connects people who don’t know where to turn for mental and behavioral services to local resources.

And again, people can checkout The Leapfrog Group to help them decide which hospitals to go to based on the availability of services and outcomes of them.

Additional Resources


If you live in a rural community, you can find its rural-urban community area (RUCA) code to see how “rural” it really is. A higher number means less access. RUCA codes are based on population density, levels of urbanization and journey-to-work commuting to characterize all U.S. census tracts with respect to their rural/urban status and commuting relationships to other census tracts.

The Cecil G. Sheps Center for Health Services Research at UNC-CH has a “financial distress” model that evaluates whether or not a hospital could potentially close.


The Rural health information Hub provides a range of information and resources about rural health, including news, reports, and analysis.


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