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AHA Details Survival Strategies for Urban, Rural Hospitals

A focus on population health, the adoption of telehealth, and a shift away from traditional inpatient offerings are a few key survival strategies for critical access hospitals and urban facilities.

By Jennifer Bresnick

- The American Hospital Association’s (AHA) Task Force on Ensuring Access in Vulnerable Communities has released a new report outlining population health strategies and best practices to ensure that patients in rural and inner city areas can reliably engage with essential health services, including primary care, urgent care, and the inpatient setting.

Population health and patient access to care

The report attempts to address the challenges of both urban and rural populations, which each face their own unique patient access barriers. 

While patients in rural communities must often travel long distances and face shortages of providers in low-population density areas, the numbers and complex socioeconomic needs of urban residents may overwhelm hospitals that are not optimally equipped to serve as the epicenter of the care continuum.

“Our goal is to address the varying healthcare issues within our country’s diverse communities,” said Robert Henkel, president and CEO of Ascension Healthcare in a press release.

“The solution to improved care is not ‘one size fits all,’ and we must continue to take into account the unique needs of individuals in both urban and rural areas. We have to continue advocating for access to quality healthcare services in the most appropriate settings for all.”

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The report notes that many hospitals in urban and rural areas serve as the first – and often only – point of contact for patients with a variety of health needs, yet a significant proportion of critical access hospitals (CAHs) and community hospitals are trying to fill this vital role while struggling with staffing shortages, inadequate resources, regulatory burdens, and a changing reimbursement landscape.

“Many hospitals face challenges maintaining access to health care services in their communities and this report provides a pathway to ensure every hospital has an opportunity to be an access point and an anchor of service,” said AHA President and CEO Rick Pollack. “The strategies outlined in this report can serve as a roadmap for all communities as hospitals begin to redefine how they provide more integrated care.”

The report begins by acknowledging that a wide range of affiliation strategies, including mergers and acquisitions, regional collaboratives, clinical affiliations, and other joint ventures, can be valuable for achieving scale and financial stability while sharing scarce resources and spreading the burdens of care across a strong network of partners.

In order to make these affiliations worthwhile for patient care, however, hospitals must engage in a multi-pronged effort to develop the accessible care options and population health strategies required to engage patients, avoid improper use of high-cost services, and address socioeconomic issues that often prevent vulnerable populations from maintaining wellness.

Addressing the social determinates of health

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As the healthcare system shifts towards a population health perspective, spurred on by outcomes-based financial incentives, providers have started to see the benefits of addressing the social determinates of health.

Some stakeholders have argued that these community and personal factors, such as housing and food insecurity, domestic and interpersonal violence, health literacy and education levels, transportation availability, and employment rates, are even more important than clinical care for determining outcomes, and that healthcare providers have a responsibility to address these issues alongside the more traditional diagnoses and prescriptions.

Healthcare organizations must first collect data about their patients and the socioeconomic barriers they face before developing strategies to ameliorate them.  The AHA report suggests that providers field patient surveys and create screening programs to identify pressing needs, then collaborate with community organizations to create and promote partnerships that will allow patients to seek the appropriate services.

Hospitals should consider devoting staff members to helping patients navigate the community services landscape, the report says, if the resources exist.

“For example, some patients may need assistance gathering the documentation required to access a particular resource; others may require help contacting the organization; still others may feel comfortable without additional assistance. The provider would use this information to create a patient-centered action plan that delineates the patient’s next steps, as well as the provider’s next steps.”

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 In order to achieve greater alignment between hospitals and social service organizations, the community may wish to create a collaborative workgroup to identify gaps in care, discuss possible solutions, and collect stakeholder feedback on existing initiatives.

Navigating the decline in inpatient services by expanding availability of other care

Value-based care strategies and the movement away from fee-for-service reimbursements have accelerated a shift in care from the inpatient setting and towards outpatient providers, reducing the financial stability of traditional hospital models. 

To cope with the reduction in inpatient volume, vulnerable hospitals should gear their investments towards enhancing their outpatient and primary care services, the AHA says, while prioritizing activities that promote wellness, prevention, and chronic disease management.

Alternatively, a greater focus on emergency care could help to bring revenue to struggling hospitals.  Emergency medical centers (EMCs) differ slightly from free-standing emergency departments.  EMCs offer immediate services around the clock, but also deliver a variety of other types of care, including primary care, observation, infusion services, and hemodialysis. 

These hybrid settings could also engage in post-acute care, such as skilled nursing and rehabilitation, in order to create a broad portfolio of offerings for the community without relying wholly on inpatient services.

Urgent care centers are another popular option for extending access to patients, the AHA notes.

“In some instances, a vulnerable rural or urban community may only need an access point for urgent medical conditions to be treated on an outpatient basis,” says the report. “In those situations, we believe an urgent care center (UCC) could be a viable alternative – allowing a vulnerable rural or urban community to have a health care resource without having to maintain emergency medical services or inpatient acute care services.”

Urgent care centers are typically less expensive than emergency departments, and they can bridge the gap between the primary care setting and the ED.  Extended hours allow immediate access for patients, and providers can perform basic trauma care such as casting and suturing.

“In some communities, UCCs also may function as the primary care practice for their patients by handling ongoing chronic conditions or serving as a formal ‘medical home’ for patients,” says the document.  “In addition, the UCC could provide enhanced service lines, such as swing beds, observation, home care or therapy, depending on the needs of the community.”

Both EMCs and UCCs should be very transparent in its marketing so that patients are clear about what services are offered and how these facilities differ from primary care, inpatient, and emergency department settings, the report stresses.

Employing virtual care strategies to enhance quality and access

Telehealth and telemedicine also offer opportunities for healthcare providers that have trouble attracting qualified staff or meeting the demands of high patient volume. 

Remote care techniques such as telestroke services have proved extremely valuable for isolated rural communities, and video consults can help smaller providers access high-quality specialty care by linking patients with clinicians at larger organizations.

“I am a strong advocate of telemedicine services,” said Jim Dickson, Chief Executive Officer, Copper Queen Community Hospital. “Through them, we are able to bring specialty care directly to our patients without time consuming and costly transport out of town and away from their family. Our partnerships with other health care organizations are fundamental to bringing this level of expertise to our patients.”

Telehealth can also address low-level complaints, including rashes or sore throats, which should receive attention but may not warrant a difficult trip to the clinic.

“Some of the most common conditions for which patients seek telehealth services are acute respiratory illnesses and skin problems, but the list of possible uses continues to grow,” the AHA says.  “Patients can connect through their smartphone for a visit with a physician related to minor illnesses such as colds, flu, bronchitis, allergy problems or rashes.”

While reimbursement and licensure remain significant barriers for many organizations, the popularity of remote care is growing rapidly as regulation catches up with patient demand.

“Virtual care strategies have the potential to result in better access to care, better care and outcomes, lower costs and workforce stability,” the report states.

In order for telehealth and other care strategies to succeed, the healthcare system will need to overhaul its reimbursement mechanisms and provide necessary funding, support, and expertise to rural and urban hospitals buckling under the strain of a quickly changing operating environment.

The AHA is planning to work with Congress, CMS, and regional stakeholders to develop models for providing implementation assistance to at-risk organizations, officials said.

“The Task Force has provided a menu of creative options, with corresponding policy recommendations, with which hospitals in vulnerable communities could lead positive transformation in health care delivery,” said Bruce Vladeck, former CMS Administrator and senior advisor, Nexera Inc. “Without such efforts, in the current environment, health care in the nation’s least well-served communities may seriously deteriorate.”

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