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Ensuring Access to Care in Urban and Rural Communities

December 7, 2016


A report from the American Hospital Association (AHA) outlines emerging strategies to help hospitals in rural and urban communities strengthen their viability in the current environment and preserve their ability to deliver services to vulnerable populations.


Developed by a 29-member task force of hospital and health system leaders and state hospital association CEOs with input from a wide range of stakeholders, the report offers “a pathway to ensure every hospital has an opportunity to be an access point and an anchor of service,” said Rick Pollack, AHA president and CEO.  “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.”


Not all of the strategies will apply to every community, the AHA notes; rather, hospitals are encouraged to select the strategies that will work best for them.


The nine emerging strategies are:

  1. Addressing the social determinants of health.  Even when healthcare services are present in a community, members of the community may be unable or unwilling to utilize these services fully due to social factors such as food insecurity, housing instability, lack of transportation, low income and unemployment, and risky or harmful health behaviors.  The report presents a model to help hospitals overcome these social barriers and reach patients.  The model includes screening patients for social needs, providing services to help patients navigate the health system, and partnering with community stakeholders to close gaps between community needs and available resources.
  2. Global budget payments.  Global payments—fixed reimbursements for fixed periods of time covering specified populations—could help hospitals in vulnerable rural and urban communities become more financially stable.  Global payments would provide incentives to hospitals to contain healthcare costs and improve quality by focusing on services that improve community health and decrease the need for hospital care.  However, global payments would need to be stable and predictable in order to enable hospitals to build the infrastructure and capabilities necessary to redesign care delivery.
  3. Inpatient/outpatient transformation.  Some hospitals could shift more resources from inpatient acute care to outpatient services.  This shift would allow them to continue providing inpatient services, but at a level that more closely mirrors their communities’ actual needs, while bolstering the quality and preventive focus of outpatient and primary care services and continuing to provide emergency care.
  4. Emergency medical centers.  Some hospitals could eliminate inpatient acute care services and become emergency medical centers (EMCs).  This strategy would enable hospitals to meet community needs for emergency and outpatient services without the financial burdens of maintaining inpatient beds.  The EMCs would provide emergency care on an outpatient basis and work with transportation services to transfer patients to other facilities as needed for inpatient care. 
  5. Urgent care centers.  Hospitals in some rural or urban communities could become urgent care centers (UCCs) to provide urgent medical services on an outpatient basis without the costs of maintaining emergency and inpatient acute care services.  These UCCs would treat patients with non-life threatening illnesses and injuries that require care within 24 hours during times when primary care offices are usually closed.  Patients would not need appointments and could receive care during evenings and weekends.  UCCs in some communities also could serve as the “medical home” for some patients and provide additional services, depending on community needs, such as observation, home care or therapy. 
  6. Virtual care.  Improvements in technology are allowing patients and providers to connect in new ways using smart phones, tablets and personal computers.  Telehealth and virtual care provide a way for hospitals to deliver immediate, 24/7 access to healthcare services in communities challenged by healthcare workforce recruitment and retention.  These virtual services can increase access, improve outcomes, reduce costs and increase workforce stability while reaching patients in the convenience of their own homes.  The range of telehealth and virtual care services is growing rapidly to include emergency and critical care services for patients in remote locations.
  7. Frontier health systems.  Many geographically isolated communities with low population density and patient volume are challenged by a weak reimbursement base.  A strategy that brings providers together in groups similar to accountable care organizations (ACOs) could provide a framework for integrated, coordinated primary and specialized healthcare in isolated areas.  The strategy would create local, integrated organizations of providers who join to coordinate preventive and primary care, extended care, inpatient care and emergency services across local, secondary and tertiary settings. 
  8. Rural hospital-health clinic integration.  Many rural hospitals have relationships with Federally Qualified Health Centers (FQHCs).  This model could be expanded to enable hospitals to form relationships with other types of health clinics, including rural health clinics and community health clinics, in which each entity would deliver services in its areas of strength.  The relationships could be based on contractual collaborations, such as agreements regarding the purchase of clinical and administrative services, or the creation of networks based on the sharing of clinical and administrative capacity.
  9. Indian Health Service strategies. American Indian and Alaska Native Tribes that receive healthcare services through the Indian Health Service (IHS) of the Department of Health and Human Services could be better served through the development of partnerships between IHS and non-IHS providers in surrounding communities.  Many IHS facilities lack sufficient behavioral health and dental care services, specialty care, and treatment for non-urgent conditions, such as arthritis, allergies and chronic conditions.  IHS facilities could conduct assessments of their services and the services available in surrounding communities to identify opportunities to share functions, consolidate services, increase efficiency and work jointly to obtain grants for expanded personnel, equipment and facilities.    


“Our goal is to address the varying healthcare issues within our country’s diverse communities,” said Robert Henkel, president and CEO of Ascension Healthcare and chair of the AHA special task force.  “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.”


In addition to the emerging strategies, the report includes information on the characteristics of vulnerable communities, a description of the essential healthcare services needed in all communities, a discussion for each strategy of existing federal and regulatory barriers to implementation and the policy and legislative changes that would be needed, and case examples and best practices.


The report is available for download here.

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