Can care guidance save rural hospitals?

The ongoing closures of rural hospitals throughout the U.S. threaten many Americans’ access to vital health care, including emergency and in-patient services. For residents who live and work within the service area of at-risk hospitals, these closures will create new barriers and drive new disparities impacting the ability to receive timely, quality care.

To mitigate this crisis, hospitals are turning to the innovative services and value proposition of care guidance. Extending beyond the scope of lay patient navigation, care guidance offers rural hospitals a truly effective solution to challenges in areas like patient satisfaction and retention, better care, new reimbursements, reduced readmissions, and shorter lengths of stay. Patients benefit with personalized support; clinical staffs are freed to focus on their clinical tasks and hospital administrators have an opportunity to improve financial performance for operational stability.

Rural Hospitals at Significant Risk

Rural hospitals are a hub for community health and well-being. Their staff, facilities and service lines provide patients with affordable, quality health care that is close to home. Research has shown how important access is to improving health equity and health outcomes. Factors such as access to transportation, travel distance, and the supply of primary care providers can also limit rural population’s ability to obtain primary care. For example, rural residents may need to travel long distances to access primary care and thus may be less likely to seek preventive care. Helping local community health care assets to thrive is a key to improving rural health. However, these facilities operate with limited resources in comparison to larger institutions and can find it significantly harder to meet community expectations to advance the “health and wealth” of area residents. Rural hospitals have fewer high margin specialty service lines to fund enhancements to routine care or to invest in extending their capabilities.

According to the Center for Healthcare Quality & Payment Reform, there are approximately 300 rural hospitals throughout the U.S. that are at immediate risk of closure. Overall, more than 600 rural hospitals – nearly 30% of all rural hospitals in the country – are at some risk of closure due to economic conditions and financial pressures.

The American Hospital Association released a report highlighting the variety of causes that resulted in rural hospital closures from 2010 to 2021, and a record 19 closures in 2020. Among the drivers are loss of revenues, increased costs, and clinical staff shortages.

Decreased Revenues

Rural hospitals often serve a segment of populations that get older and fewer over time as younger generations migrate to larger urban settings. Fewer patients to serve equates to lower demand for medical service and less revenue. Projected revenues typically fall short of generating enough contribution margin to cover operating costs.

This is compounded by a surging rate of national inflation that adds to the total cost of care and results in even narrower margins. Recent changes in reimbursement structures can also have a significant impact on payments to rural providers and can have the impact of decreasing hospital revenues. In rural areas with higher rates of uninsured or underinsured patients, hospitals may face difficulties in recovering unpaid billing and be left with absorbing the cost of charity care.

Avoidable Readmissions

Beyond reimbursement and population demographics, rural hospitals also struggle with readmissions. Readmissions disrupt and erode the quality care delivery and continue to be associated with a significant proportion of health care costs. While not all readmissions are avoidable, a portion can be anticipated and prevented pre-and-post-discharge and during their continuation of care. It is especially important for rural hospitals to prevent unreimbursed readmissions that can cost, on average, upwards of $20,000 per patient.

A sustainability strategy should consider the needs and perspectives of the patient base and clinical staff to implement the right approach that renders care efficiencies, lowers costs, and increase revenue to sustain operations and service.

Patient Perspective: Understand Risk and Vulnerability of Non-Clinical Factors

More than 60 million Americans live in rural areas. The demographics are generally of lower income, older age, and more likely to be in poorer health conditions compared with those living in urban areas with access to larger health systems.

Identifying patients who are most at-risk requires taking into account the full spectrum of a patient’s health as well as their socioeconomic conditions.

Rural hospitals must recognize the impact non-clinical issues have on rural populations and understand how they underlie health inequities and disparities. For example, social determinants of health (SDoH) can impact a patient’s ability to access and receive care and adhere to clinical instructions. These non-clinical factors include housing, food and nutrition, transportation, social and economic mobility, education, and environmental conditions. If SDoH issues and their potential barriers to care are not promptly resolved, they can lead to health deterioration, costly utilization of clinical services and extended hospitalizations.

Provider Perspective: Clinical Staff Shortages

Clinical staff shortages can be difficult to absorb, and rural hospitals face significant staffing shortages. In fact, nearly 70% of the primary care Health Professional Shortage Areas (HPSAs) are located in rural or partially rural areas. The lack of essential medical staff can limit the hospital's ability to provide adequate care, service lines and limiting resources to handle complex medical cases. This in turn can cause a vicious cycle where patients leave the local area for larger facilities in more urban communities for treatment (which can be more expensive), which in turn further negatively impacts the rural hospital’s finances and ability to deliver critical care. McKinsey advises that worsening clinical labor shortage will contribute to projected increases in health care costs over the next five years.

Nurses are a crucial ‘glue’ in the relationship between rural populations and rural hospitals. With a shortage of doctors and pressing time needs, nurses are frequently forced into a more expansive communication and navigation role in these locations. Significantly, nurses report that a huge amount their workload is burdened by addressing non-clinical patient issues and practical tasks, like scheduling follow-up visits, ensuring transportation and attending to a myriad of issues. Anywhere from 10-20% of patient issues are being recorded as clinical, physical barriers while the other 70-80% come from practical, non-clinical barriers.

The recent American Organization for Nursing Leadership’s compendium of workplace best practices recommends looking for opportunities to offload time-consuming tasks for nurses.

Care Guidance Solution

The integral role of care guidance, also referred to as “care navigation” serves as an extension of a hospital’s clinical team to support a range of care management activities, including facilitating post-discharge transition and continuation of care. These programs are focused on prevention by proactively interacting with patients to understand and resolve their care barriers - before non-clinical issues become problematic and costly.

How Care Guidance Works

The primary goal of care guidance is to ensure that the patient receives the right care at the right time, in the right place and with the right outcome. This is accomplished through specially selected and tech-enabled “care guides” who work to establish a peer-to-patient connection with patients and their families. This human-led approach builds trust, lowers a patient’s resistance to sharing information and helps to uncover potential barriers they encounter.

Optimally, care guides are equipped with scalable technology platforms that provide structured workflows and use evidence-based disease and condition-specific protocols to proactively identify and resolve non-clinical barriers while also using standard symptom assessments. Through this level of support, care guides ensure that patients are enrolled in the most applicable and supportive programs, such as chronic care management, and can make sure patients are taking advantage of their annual wellness visit benefits. Moreover, when care guides are engaged with patients, clinical issues can be found and immediately escalated to proper clinical care teams.

The human element of care guidance is especially important as digital engagement simply cannot be a replacement for the human aspect of patient interaction. This is especially true considering the limited abilities rural populations have in accessing digital technologies, and potential use impairments among disabled, disadvantaged, and senior populations. Human and tech elements, integrated together, are effective in identifying practical issues and enabling proactive resolution of non-clinical barriers to a patient’s continuum of care along their health care journey.

Value of a Care Guidance Program

A successful care guidance program renders a return on investment through improved efficiencies, reduced time and resource allocation, and cost of overutilizing clinical care teams. As more hospitals experience the profound impact of nurse shortages, care guidance is providing an innovative solution.

Care guidance is of especially high value in alleviating non-clinical tasks and its support of navigating patients through the complexities of the healthcare system. For example, helping patients understanding their discharge instructions, scheduling follow-up appointments, medication fulfilment and compliance and ensuring needed transportation highlight the importance of connected care and patient activation.

New Revenue Opportunities and Partnerships

Since the introduction of reimbursement for chronic care management and annual wellness visits, CMS has consistently increased payments rates to advance this important aspect of connected care for patients experiencing multiple complex conditions. With better reimbursement rates for CCM and AWV in their markets, rural hospitals need to adopt strategies to maximize their ability to collect these revenue streams by optimizing assigned CPT codes and maximizing reimbursements.

For rural hospitals, partnerships can be effective options to sustain service lines and access to care in their communities. This type of collaboration has increased significantly in the past decade, with hospitals and health systems looking to create operational, strategic and financial value to help them meet their mission of caring for patients and communities. For example, a hospital that does not offer a particular service line may seek a joint venture partnership with a leading organization in the field. These integrations not only preserve patient access to care, but they can also enhance quality of care.

Care guidance is rapidly becoming a “must-have” addition to the service portfolio of health systems, hospitals and provider organizations. It is at the nexus of new managed care priorities where care guidance represents an innovative approach to advancing heath equity and delivering high-value, high-quality care. Attempting to allocate internal resources to perform the tasks that fall within the scope of care guides could potentially be both inefficient and costly.

When an outsourced care guidance program is well designed, implemented and managed, it can provide a significant upside for the hospital, its clinical staff and patients.

Through a care guidance partnership, clinical staff receive the extended support they need to ensure the delivery of equitable while collaborating with care guides to enhance patient experience, satisfaction and resumption of functioning and quality of life. This is where the proposition of a care guidance solution presents the most value for shareholders a validated approach to equitable and sustainable care.

About the Author

Craig Parker, CEO, Guideway Care, has spent most of the last twenty-five years operationalizing solutions that leverage technology and people to improve patient care and outcomes.