For rural communities, pandemic compounds strained health care systems
As COVID-19 has made its way from high-density cities into rural areas, health care systems that are stretched thin under routine circumstances now have the added stress of caring for their communities during a global pandemic.
Between 10 and 20 rural hospitals close across the country each year, and Texas has seen more closures than any other state. With limited funding and resources, the novel coronavirus—which White House coronavirus task force coordinator Dr. Deborah Birx said last month is now “extraordinarily widespread” in rural areas—creates more pressure.
The Texas A&M University Rural and Community Health Institute has contracted with more than 100 rural hospitals in Texas to provide solutions for certain programs and services they can’t provide on their own, including quality improvement, peer review and database management.
Executive Director Nancy Dickey, MD, who is a president emeritus of the Texas A&M University Health Science Center (Texas A&M Health), said the pandemic is another challenge for small rural hospitals already struggling to keep their doors open.
“Their profit margin is just a hair wide, and so when suddenly for months all elective procedures stopped, they don’t have reserves that will continue to pay their personnel, pay their light bill, pay the other costs associated with keeping a hospital open,” she said. “And that put many of them in increasing jeopardy of closing their doors.”
Added to the systemic health issues facing rural residents, this creates a precarious situation. According to the Centers for Disease Control and Prevention, rural Americans generally have higher rates of obesity, high blood pressure and smoking, and are less likely to have health insurance.
Statistically, the populations of small towns—generally considered those with less than 25,000 residents—are older and sicker than the populations of urban areas, Dickey said. Often they face substantial distances to receive specialty care and to seek out a tertiary hospital.
“For some of our residents that live in rural communities, when a hospital closes they’re over an hour away from health care. That paves a way for chronic disease,” said Bree Watzak, PharmD, director of technical assistance for the institute’s patient safety organization. “If you can’t get to see your doctor when you need to, the disease just gets worse.”
These factors put rural Americans at higher risk for COVID-19. Watzak said rural areas also include more households with many people living under one roof, and residents with jobs that can’t be done from home to reduce exposure to the virus. “Unfortunately, the circumstances add up,” she said.
Every hospital the institute interacts with has said that COVID-19 has affected its day-to-day business and threatened its financial bottom line, Dickey said.
Additionally, many do not have an intensive care unit, or have only one or two ventilators to stabilize patients before sending them to larger hospitals for treatment. Smaller hospitals have often been at the bottom of the list when it comes to supplying personal protective equipment, Dickey said, even though they continue to see patients in emergency rooms and screen people for COVID-19.
“They often were not getting the same kinds of supplies that bigger hospitals were getting, and they also have a very small pool of employees,” Dickey said. “So if they had a physician or a nurse who contracted coronavirus and was going to be out for two or more weeks, that did have a tremendous impact on a number of those hospitals.”
At the same time, the pandemic has introduced some positive things to rural health care systems, like more formal agreements between tertiary care centers. As the state has wrestled with whether it would reach the capacity issues seen on the East Coast, Dickey said the Rural and Community Health Institute helped put processes and agreements in place for small hospitals to take on some COVID-19 patients to prevent hospitals in large cities from being overwhelmed. Lines of communication opened between rural and tertiary physicians and transfers were discussed to limit overload on either end.
“There are a couple of exceptional examples where the small hospital staff came together and said, here are the things where we can effectively and appropriately give coronavirus patients high quality care,” Dickey said. “Those agreements occurred in a number of cases and are a model for what should be happening without the coronavirus.”
There has also been expansion to access in telemedicine through the waiver of several regulatory barriers. Watzak said the next step will be to see whether the relaxation of the rules can be kept moving forward, because “they’ve been very helpful to hospitals.”
“It’s helped increase access to care for people in rural areas, so it’s something we’d like to keep,” she said.
Watzak also points to the ways that two rural hospitals, Titus Regional Medical Center in Mount Pleasant and Hill Country Memorial Hospital in Fredericksburg, embraced social media to educate residents about the virus.
“Any time there’s a crisis, one thing you want to do is look to the positives, and one of those should be that maybe we have opened some eyes about the importance of rural hospitals, the beds they offer and quality of care closer to home,” Dickey said.