Wednesday January 24th 2018

A challenging road

Nurses discuss complexities, ways to address rural health care

Registered nurse Sharon Webster, manager of the Hannibal Free Clinic located roughly 100 miles from St. Louis, MO, describes practicing in a rural area this way: “We’re neighbors helping neighbors.”

That’s one of the job characteristics nurses in rural communities say they find rewarding. But rural health care has its challenges, from workforce needs to hospital closings.

According to the Federal Office of Rural Health Policy, some 57 million persons nationwide, or 1 in 5 Americans, live in rural communities. Yet 55 rural hospitals have closed since 2010, and 283 more are disturbingly close to shutting their doors, the National Rural Health Association recently reported.

The ongoing financial struggles of rural facilities have many health care professionals on edge — worried about the impact that more hospital closings will have on the health and well-being of their patients, their communities and the nation as a whole.

Sallie Poepsel

“It’s really an alarming trend that can result in the United States having health care deserts,” said Sallie Poepsel, PhD, CRNA, a U.S. Health and Human Services appointee to the National Advisory Committee on Rural Health and Human Services. “Rural hospitals do the best they can, but they often don’t have the resources they need.”

A challenging rural landscape

When envisioning Nevada, what first comes to mind is more likely Las Vegas nightlife than rural life. But as a resident of northeastern Nevada, Heidi Johnston, MSN, RN, CNE, knows the geographic realities and what they mean for health care. The city nearest her, Elko, has a population of about 18,000.

“I’ve been in Elko half my life and have a huge, vested interest in caring for my friends and neighbors,” said Johnston, a Nevada Nurses Association member and an instructor and health sciences department chair at Great Basin College. Like other areas across America, rural Nevada has a high percentage of uninsured and underinsured residents, many of whom are older and battle chronic illnesses, such as heart failure and COPD.

“We don’t have specialists in Elko, so residents, including those who need chemotherapy, have to travel four hours one way to get to a [bigger] city,” said Johnston, who also works per diem in med-surg and OB at a 75-bed hospital. “And when you consider gas, food and the cost of a hotel — access to care gets even more challenging.”

When a hospital closes, it can make obtaining even “traditional” services vexing. For example when the hospital in Tonopah, NV, (population 2,000) shut its doors, it left young families with no OB coverage, noted Johnston, who was instrumental in starting NNA’s Rural and Frontier Nurse Advisory Committee. With 115 miles separating most rural hospitals, traveling for routine appointments and emergent care is far from ideal.

The need for ongoing or specialized care is also a struggle in agricultural communities in Minnesota, said ANA-Minnesota member Brandi Sillerud, DNP, MSN, RN, NEA-BC.

“Patients spend more time in hospitals because there often isn’t enough staff in long term care to take any admissions,” said Sillerud, assistant professor of nursing at Minnesota State University Moorhead and a house supervisor at Lake Region Healthcare. There also is a lack of beds, funding and providers for mental health and chemical dependency care, which further strains community hospital staff and finances.

Other challenges prevail — some not necessarily unique to rural America.

Cynthia McArthur-Kearney

In eastern North Carolina where Cynthia McArthur-Kearney, DHA, MSN, RN, NE-BC, practices, health literacy and language barriers can have a significant impact on communication between nurses and patients.

“We see patients with various chronic diseases, such as diabetes, heart disease and persistent renal problems, who often need continuous education to properly manage their conditions,” said McArthur-Kearney, manager of Education Services at Southeastern Health, which serves a diverse community.

“Many struggle with understanding how to appropriately take their medication, eat healthy and adhere to a basic exercise regimen, which means they are more likely to experience poor health outcomes.

“So nurses play an important role in providing education to patients by breaking down communication and language barriers that impede patients’ ability to perform effective self-care.”

Sillerud described yet another pervasive problem, at least in her rural community.

“We see a lot of people — many farmers — who may have the financial resources but think, ‘I don’t have to go to the doctor unless I’m sick,’” she said. “So instead of getting preventive care, they wait longer to come in and then it becomes a reactive model of care.”

Funding, regs and diversification

When it comes to rural hospitals, reimbursement is not equal.

For example, hospitals that qualify as critical access facilities, which have 25 beds or less and meet other federal requirements, are essentially reimbursed fully for their services.  Larger tertiary care centers handling more complex care also generally fare better, but community — or  “tweener” — hospitals are usually reimbursed below cost,
Sillerud said.

“And they’re so needed, because they can provide more types of care right in their communities,” she stressed.

In a report by U.S. Sen. Al Franken (D-MN), co-chair of the Senate Rural Health Caucus, rural providers deal with “regulations, administrative burdens and policies that strain their resources and create problems for them and their patients.”

Nancy Fredrich, BSN, RN, CIC, director of quality, compliance and infection control at Cooper County Memorial Hospital in Missouri, agrees, saying, “Small rural hospitals have to meet every regulation that larger, urban hospitals do, and are held to the same quality measures.” But when the patient pool is much smaller, scores on quality measures may be skewed — making it appear as though they are performing much less effectively than larger hospitals. And those scores can affect reimbursement.

Currently there is federal legislation that would provide financial and regulatory relief to rural hospitals. The American Nurses Association and nurses such as Poepsel support this measure, which is called the Save Rural Hospitals Act (H.R.  3235) and was introduced by U.S. Reps. Sam Graves (R-MO) and Dave Loebsack (D-IA).

Rural facilities also are working to strengthen their relationships with their communities and diversify their services.

“We’re very enmeshed in our community, which was started 45 years ago by a group of local leaders who went door to door to build this hospital [Hill Country Memorial],” said Maureen Polivka, JD, BSN, RN, chief nursing officer of the Fredricksburg, TX, hospital and a Texas Nurses Association member. Public support has continued, with ongoing donations made to the hospital’s foundation to pay for medical equipment, new technology and other crucial needs.

“We give back by keeping residents healthy and providing the services they need,” she said. For example, the hospital partners with a farmer’s market to provide information to residents on nutrition and healthy recipes, and with a local clinic to offer free employee health screenings and wellness-focused educational programs.

“And while providing whole person care is not unique to rural care, it’s magnified here because nurses and other providers will see their patients in the grocery store,” Polivka said. So there needs to be even more of a connection between nurses and their patients.”

Polivka additionally credits Hill Country’s first CEO for having the foresight 20 years ago to plan for potentially decreasing levels of inpatient care by developing hospice and home care services, as well as opening a wellness center. That early planning has positioned the hospital to better withstand financial challenges.

Seeking more solutions

Rural nurses and Franken’s report point out ongoing challenges in recruiting and retaining nurses and other providers.

“We’ve been trying to recruit a primary care physician for close to a year,” Polivka said. Nurses and physicians who might want to practice in a rural area also must consider whether there are jobs for their spouses, too, which adds to the challenge.

Polivka, Johnston and other nurses say one vital way to have the nursing workforce they need is by supporting a “home-grown” strategy. For example, Johnston’s nursing program at Great Basin College — the only one that serves rural Nevada — just received a grant to expand its program to other sites within the state.

“We’re bringing education to [nursing students], which will help increase the number of nurses interested in providing rural health care,” Johnston said.

She and other members of the NNA Rural and Frontier Nurse Advisory Committee also are looking at ways to support practicing rural nurses by providing them with more educational resources and opportunities to network and collaborate with their colleagues statewide.

Sharon Webster

Other key solutions to boosting access to quality care are ensuring nurse practitioners and other advanced practice registered nurses, whom Poepsel calls the safety net providers, can practice to their full scope and education, and increasing the use of telehealth. The latter, however, means increasing access to technology and the internet, as well as ensuring the stability of internet connections.

McArthur-Kearney believes in improving the utilization of clinics to provide rural residents with increased access to preventive care and chronic disease management.  And Sillerud emphasizes that having more nurses in care coordination roles also is critical.

Back in Missouri, Webster knows that the services rural nurses and other staff provide at the Hannibal Free Clinic matter. She’s witnessed firsthand a patient who received life-saving cancer treatment because of an assessment performed by clinic staff, and another patient whose diabetes is now effectively managed after coming into the clinic with a blood glucose level of 1,300.

And Fredrich knows how much rural hospitals mean to their communities.

“Older people especially don’t want to, or can’t, drive to a major hospital farther away,” she said. “They feel they will be just a number.”

— Susan Trossman is a writer/editor for ANA.

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