Seven ways rural health care is changing

by Wendy Royston

Additional reporting by Doug Card, Britton Journal; Ken Schmierer; Bill Krikac, Clark County Courier; Sarah Gackle and Heidi Marttila-Losure

Say “country doctor” and you might think of a genial, gray-haired man who makes house calls with his black bag. Today, rural medicine is vastly different from that image—and as we look into the future, it’s going to change even more. Most of these changes have the potential to improve health outcomes, but as with all changes, acting mindfully will help us ensure we don’t lose something of value in the process. Here are seven ways that health care is going to be different in the years to come—starting now.

1. As baby boomers age, the need for health care will increase.

One of the biggest trends in rural health care cuts two ways: More people will soon require increased care, but fewer professionals will be available to provide it.

“South Dakota communities are aging,” said Dave Rogers, CEO of Sanford Webster (S.D.) Medical Center. “There is going to be a continued demand for senior services, home health, senior living, assisted living, or nursing homes.”

The youngest of the “baby boomers”—the large number of people born in the post­-World War II war era, between 1946 and 1964—is turning 50 this year. As they get older, the age of the United States overall will skew older: “By 2030, more than 20 percent of U.S. residents are projected to be age 65 or older, compared with 13 percent in 2010 (before any of the baby boomers turned 65) and 9.8 percent in 1970,” according to a June story in U.S. News & World Report. Older people require more health care in general; aging baby boomers will require more care than current seniors do just because there are more of them.

But baby boomers are also anticipated to demand more amenities, more entertainment and more privacy than their parents, according to Tony Hanson, administrator/CEO of Avera Clinic of Ellendale (N.D.).

“Baby boomers (are) now reaching the age that they need another level of independence,” said Nick Fosness, administrator of Marshall County Healthcare Center in Britton, S.D. “We’re looking at other services such as independent living and home ­care/senior care needed in our area. The question is: How are we equipped as a small town to have services to offer right here? We’ve just finished up some strategic planning for the next 10 years, and we’re trying to identify who we’re going to be and what services we will be providing 10 years from now.”

2. Finding health care providers is hard, and will only get harder.

The same demographics that are increasing the need for health care are also decreasing the number of health care providers, as some of the baby boomers who may soon require more health care were in professions where they were providing it.

“Because of the demographic shift, we’re seeing a lot of people retire who are caregivers, and I think it’s going to be harder and harder to fill health care jobs,” said Todd Forkel, administrator of Avera St. Luke’s Hospital in Aberdeen (S.D.)

Serving the needs of the aging baby boom generation with the smaller generations that followed will present challenges nationwide, but the need will be particularly acute in many rural areas, where the population already skews older than the national average.

As with a lot of rural businesses, Dave Rogers said, the demand for the service is there, but the people to provide the service are not.

Already now, nursing homes in many rural areas are using expensive contracting services to fill gaps in their workforce. In Day County, S.D., workers from Illinois come to the Webster area to work in nursing homes for a few weeks at a time, Rogers said. Needs range from certified nurse’s aides, which require no experience, to nurses, doctors and specialists.

“We need to have a push to get people excited about being in these health care jobs, from top to bottom,” Forkel said.

3. Health care will be forced to become more efficient.

A year ago, Congress cut Medicaid and Medicare reimbursements by 2 percent. Looking ahead, health care officials anticipate increased pressure to provide quality care at a lower cost.

“Two major factors are driving that—more and more baby boomers are retiring, so the pressures on the Medicare system are causing this, and then health care grew to become unaffordable,” Todd Forkel said. “I think we, as an industry, need to figure out how we can get high­ quality health care to be affordable. … There’s going to be much greater pressure around reimbursement. Whether you’re a critical access hospital or a (larger) hospital like Aberdeen is, health care is not affordable throughout the country, so we need to figure out how to deliver a higher quality of care for a lesser price.”

Dan Ellis, CEO of Coteau des Prairies Hospital in Sisseton, S.D., added that the amount that hospitals receive in reimbursement will be directly affected by the quality of care given to patients.“The Affordable Care Act is dictating that—to receive the best reimbursement rates—you do need to comply with their standards with regard to getting paid for performance, and the prime insurance plans are moving that direction as well,” Ellis said.  “Both rural and metropolitan area providers will have to become more compliant with what’s in the Affordable Care Act, as far as getting paid for performance,  providing more quality care in terms of complying with certain quality standards in order to receive certain levels of reimbursement—from not just the government, but from private insurance plans as well.”

And, as Congress considers removing the 1 percent margin it has paid to smaller, rural hospitals on top of expense reimbursement, some administrators are concerned.

“If they take away that 1 percent from us, then we will have a really hard time making ends meet,” said Gaea Blue, administrator of Avera Weskota Memorial Hospital in Wessington Springs, S.D.

Dave Rogers pointed out the challenge this presents to rural communities. “When critical access hospitals were set up (in the 1990s), a lot of hospitals were going to close,” Rogers said. Some rural residents would have had to drive 50 miles or more for basic health care. The critical access hospital designation provided extra funding to help those hospitals stay open.  As leaders on the federal level look for efficiencies in the health care system, they may no longer find those hospitals as “critical,” Rogers said, even though the distances to other providers have not changed.

“In the 1990s, (they said,) ‘We need you,’” Rogers said. “Now the community needs us, the state needs us … but at the national level there’s a disconnect in enabling critical access.”

4. Technology will dramatically change how we receive health care.

Health care administrators in the Dakotas interviewed for this story were united in one theme: In a hundred ways, both big and small, technology is the change that is having the biggest impact on rural health care.

Electronic records

The move to electronic records, encouraged by the American Recovery and Reinvestment Act of 2009, made perhaps the biggest splash so far.

“The biggest change that I’ve seen over the last 20 years in rural health care is the automation of the records,” said Luann Streff, physician’s assistant at Sanford Clark (S.D.) Medical Clinic. “There are pluses and minuses having everything computerized, but it definitely has brought about a better sharing of the records.”

“If you don’t go to electronic records, you will become obsolete,” Todd Forkel agreed.

There is room for improvement. Some better compatibility between different systems and more user-­friendly devices are needed, according to surveys  of physicians, and many health care providers are not using electronic records at the level that the federal government would like (few health care providers have reached the second stage of the “meaningful use” standards included in the legislation). But those electronic records set the stage for many other technological health innovations—some of them already happening.

Bringing specialists to rural

Tony Hanson said a “virtual revolution in health care delivery” is underway, and rural care is positioned to get better as technology “eliminates distance.”

In Marshall County, for example, technology has given health care providers the ability to provide digital mammography and CT scans, according to Nick Fosness. “We’re now able to do things like colonoscopies so patients don’t need to travel,” he said. “And sleep studies is now a service we’re doing here. Someone can come in at 7 p.m., spend the night, and be out of here by 6 a.m. and back to the office with the information monitored and read in Minnesota. That’s technology at work.”

Streff said new technology has sped up the abilities of providers to diagnose and treat a patient’s condition.“(Digital radiography) allows us to read images in real time,” she said. “We then can interact immediately and directly with the patient.”

Fosness said providing services “at home” is a huge asset to communities like Britton, which is 60 miles from the closest community—Aberdeen—with a larger hospital.

“We’re having more conversations about what else we can do in a small town and assessing what works in Marshall County,” Fosness said. “We want to do things that mean something and save miles for those who live here, and there are a lot of services we can do very well here.”

Specialized care is increasingly available in smaller communities, according to Forkel: Ten years ago, patients would have had to drive to the Mayo Clinic in Rochester, Minn., for certain things that now can be done in Sioux Falls or even Redfield.

Streff said her clinic is looking at new technologies that can help them provide the best possible service to local patients.

“Two areas we already are exploring are the e-­visits, where one is treated and diagnosed by computer, and Skype-­like visits whereby one sits in front of a computer,” she said, adding that some limitations are imposed upon so-­called “virtual visits,” but that Sanford is using them on a limited basis already.

Lane Nelson, owner of Edgeley (N.D.) Pharm Store, said virtual visits will be beneficial for providers. “The phone service will take the pressure off family doctors who are spending a large portion of their time on easily treatable bugs,” she said. “This will free them up to spend more of their face-­to­face time on conversations around lifestyle issues.”

Technology such as eEmergency can be beneficial to rural communities’ efforts to recruit physicians, according to Gaea Blue. “When the practitioner on call at night is all alone, and particularly if they’re someone who is new out of residency, (there is) someone else they can get input from,” she said. “Otherwise, a less-­experienced practitioner is leery of coming to a smaller community, where they know they’ll be all alone.”

Losing in-person conversations

Eventually, Nelson thinks “vending machine pharmacies” will make their way across the Midwest, as they already have hit other parts of the nation. Nelson worries that vital person-­to-­person connections might be lost in the process.

“People demand cheap before they demand service, and to do cheap, you have to drop labor costs or consolidate them,” she said. “But losing labor moves the system away from personal service. However, study after study has shown that the faith of a patient in their practitioner is directly correlated with the success of the treatment. If we get to phone ­call doctor visits and vending machine pharmacies, we are completely undermining the personal relationship and its success in treatment. The times when I have felt I’ve made a big difference, it came from conversation and relationship, not a standard Q&A and prescription.”

Less ­personal pharmacy structures are already in place in some areas of the Dakotas, however. Some medical professionals are pleased with the result.

“In a rural hospital, we do not have a pharmacist who is on staff all of the time,” Blue said. “Our local pharmacist … she comes out every day … but that’s difficult to meet the regulations, because you need someone to review the prescriptions.”

In instances when the local pharmacist is unavailable, Avera’s ePharmacy service allows Sioux Falls pharmacists to oversee local doctors’ prescribing methods from a distance through telemedicine.

“That’s very valuable for us, in conjunction with our local pharmacy and our local staff,” she said.

Dave Rogers thinks sparsely populated rural areas could be served in the future with mobile clinics, which may have no trained medical person on site at all: A layperson could sit the person down in the exam room and hook them up to a computer that takes blood pressure, temperature and other readings. That information would be sent to a physician at a larger regional hub, or to a specialist at a place like Mayo Clinic. Patients would have to decide for themselves whether care provided close to home but over technology is a good trade­off for drivingfor an in-­person visit, Rogers said.

“How (health) care will be delivered, and how we define care, is a lot different (compared) to how we defined care a decade ago,” he said. “We want to keep care close to home. Each individual will have to judge whether it’s something they are comfortable with.”

5. Most rural health care will become part of a larger network.

The pressure to increase efficiency along with the desire to adopt technologies that can improve health outcomes will make one more change likely: Most rural health care facilities will be part of regional networks.

“I just read an article that many critical access hospitals need to be a part of a larger system to survive, and we’re finding that to be true,” Gaea Blue said. The Wessington Springs hospital became affiliated with Avera in 2000, and Blue says that partnership has been a blessing to the community. The larger Avera network helps with staffing and management, as well as providing larger­ scale technology and specialists the hospital could not independently fund.

“People are surprised what all is under one roof in one campus,” Blue said, referring to the campus’s nursing home, two independent living apartment complexes and clinic, as well as the facility’s ability to provide services such as physical therapy and various higher­ end imaging-­type tests, such as CT scan, mammography and ultrasound.

Marshall County Healthcare Center in Britton is another Avera affiliate, and administrator Nick Fosness agrees that affiliation with the larger system is beneficial to his facility and his community.

“We have a very strong partnership with Avera,” he said. “That gives us access to many more resources we would not otherwise have. …  Without that partnership, it would be difficult to access the … resources we need.”

Tony Hanson said the partnerships among health care facilities in recent years have been refreshing. He pointed out the systems at­ large, such as Sanford and Avera—the area’s largest chains—are working together to improve the quality of care patients receive. It is interesting, he said, that in Ellendale, the Avera clinic contracts with Sanford doctors for physician’s assistants.

Valerie Martin, who was the director of nursing at Ellendale’s private hospital when it closed and now is a physician’s assistant at the Avera Clinic of Ellendale, said the community was concerned when the hospital shut its doors. In retrospect, Martin said the hospital really was not full ­service, and could not handle most emergencies, but was more of a psychological boost to the community. But not all health care professionals agree that large­system takeovers are not in the best interest of patients—especially those in rural areas.

“There is a general decrease in providers because of large takeovers. Fewer clinics and fewer owners of those clinics means less choice for patients,” Lane Nelson said. “Rural health care is becoming a subsidiary of conglomerates that have no connection to rural life. A corporate decision maker in Chicago may decide what computer system the clinics should use, but that person has no idea how we operate. Rural is nothing like the East or West Coast. When those are the people making the decisions, they aren’t able to make decisions that are pertinent to our lives.”

6. People will stay less in health care facilities and spend more time at home.

From the time spent in hospitals for procedures to delayed entry into nursing homes, health care is increasingly being provided to people in their homes—and that trend is only going to get stronger as technology improves and pressure to reduce costs increases.

Fewer, shorter hospital stays

Many rural hospitals now see far fewer in­patient visits. When the hospital in Wessington Springs opened in the 1970s, patients “came into the hospital and stayed in a length of time, for anything from having a baby to any other reason,” said administrator Gaea Blue. “The people were admitted to the hospital more quickly, (and) they stayed longer.”

Now, she said, the length of stay averages three days, and there are more outpatient services. Inpatient visits have decreased in part because many hospital procedures are less invasive than they once were and require less recovery time.

For example, “a one­-month hospitalization from a hip replacement is now one week,” Nick Fosness said.

Many studies suggest patients recover better in their homes, Tony Hanson said. They get up and move more quickly, and are able to rest in a quieter environment.

But the change has been forced by policy as well: For many procedures, Medicare and private insurance companies have reduced the number of recovery days they will pay for, or they say what used to be an inpatient procedure is now an out­patient one.

The move toward more outpatient care has changed the facility needs of rural organizations, Fosness said. “We no longer have the need for a 20-­bed hospital,” he said. “We see days of 10 to 11 patients, but that is about the max.”

Unfortunately, the change has also made it more difficult for rural hospitals to get enough revenue. Dave Rogers explained that it takes nine outpatient visits to provide the same revenue as one inpatient visit—so providers have to handle many more patients to get the same revenue.

Increasing elder care at home

Staying home as long as possible is a goal for most people as they age. One way that care providers are helping seniors stay in their homes longer is through adult day health centers.

Bethesda of Aberdeen has the first adult day health center in the region. “We’re really excited to be ahead of the curve in providing these services,” said Peggy Larson, director of development and community relations at Bethesda. “(The Bethesda board) had data that this type of program was definitely needed in this community and the region.”

Seniors who no longer can live on their own, but require minimal assistance, can live with their children or other caregivers and visit a facility for part­time care as needed.  The concept provides the caregivers a break from their duties, and also gives the patient an opportunity to take part in activities or receive health care services. The adult day health center in Aberdeen offers spa care, social opportunities with other seniors, therapy services, medication monitoring, nurse liaisons to physicians, managed nutrition and personal care assistance.

“It would prolong the time (a senior) was able to live at home, either with family or on (their) own,” Larson said. “Every person who comes will have their own care plan. It really is a health care model.”

The center could be used by families who do not live in Aberdeen but visit there for shopping or other services. For example, one farmer is planning to bring his wife, who has dementia, to the adult day health center once a month when he comes to Aberdeen to conduct his farm business, Larson said.

7. Health care will increasingly focus on keeping us healthy rather than treating illness.

Start talking about “health” and you usually end up talking about its opposite. One trend in health care is taking the conversation in a different direction: The Affordable Care Act is effectively helping promote a culture of health care that is proactive to wellness, rather than reactive to illness, according to many hospital administrators.

“It’s helping us try to take the focus off disease ­management, and move it over to prevention,” Gaea Blue said.

Todd Forkel agreed: “You’re going to see us (doing) more than just taking care of people episodically when they aren’t feeling well,” he said.

Tony Hanson said this shift is in line with Americans’ goals in general. “People are generally healthier and more interested in healthful living,” Hanson said. “We’re going to see a switch from sick care to wellness. … These are good things.”

Those “good things” also have been promoted by private insurance companies, according to Dan Ellis. “They want to see you doing more preventative care for your patients, keeping them well, decreasing the insurance care costs, in terms of reducing the cost of care that maybe should have been prevented,” he said.

Dave Rogers said some of these wellness efforts will be condition ­specific, such as education and emergency prevention methods for diabetic patients.

“It is cheaper to do preventative medicine than it is to pay for someone going to ER five times a month because they are not managing their medications,” he said.

Additionally, health care facilities are reaching out into people’s everyday lives.

“Promoting community health is (a) key area,” Nick Fosness said. “That is one of the best ways to ensure that your future is solid. Those hospitals who have focused on promoting health will be ones looked at as a healthy place and will survive. We want people to see us as the place where they can have confidence.”

One such attempt at many rural facilities, including in Britton, is to offer access to wellness centers.“We’ve invested into a 24/7 community wellness center with very affordable rates,  and we promote multiple wellness activities throughout the year,” Fosness said.

Through the wellness center, activities such as wellness carnivals and “couch to 5K” programs encourage healthy lifestyles outside of the facility, and Fosness said the community’s support was evident in 2005, when they set out to build a more than $2 million facility.

“We accepted maybe a $200,000 interest-­free loan (which has since been paid off), but the rest of it—to the tune of a little over $2 million—was directed from the community in a matter of months,” Fosness said. “The community here supports wellness, and supports our facility, and that’s a really important facet of keeping a rural facility and keep the quality of providers available locally. If you lose the confidence of your small town, you lose your business elsewhere, and you have nowhere else to draw from.”The wellness center, he said, is an “investment back into our community.”