Rural healthcare providers can pursue multifaceted strategies to improve care availability, accessibility, and affordability.
Care access is a pressing problem in rural areas of the country because it impacts the quality of care that patients receive, according to a recent National Quality Forum report.
"Access and quality are intertwined and difficult to de-link," the NQF report says.
The report's recommendations on care access in rural areas are based on several assumptions:
- Long distances to care sites and lack of transportation are major barriers to care access
- Telehealth is a potential solution but has drawbacks such as needing to travel to a medical practice to use a secure telehealth service
- Staffing shortages such as limited numbers of specialists are a driver of care access problems in rural areas
- Quality measures for healthcare providers could be improved by risk adjustment for factors in the rural environment, including social determinants of health and transportation needs
Risk-adjusting quality measures for social factors would benefit rural healthcare providers and their patients, says Elisa Munthali, senior vice president for quality measurement at NQF, which is based in Washington, DC.
"Risk adjusting would make measures a fairer assessment of the quality of care that providers give to rural residents. It would account for the challenges they are facing that can prevent them from providing more comprehensive care," Munthali told HealthLeaders this week.
"To the extent that we want to recognize those challenges in measurements, it would be good for providers because we could start talking about the actual quality they are delivering for their residents," she says.
To improve rural care access, the NQF report focuses on three sets of recommendations: availability, accessibility and affordability.
The report says the most important elements of healthcare availability in rural areas are access to after-hours and same-day appointments, access to specialty care, and timeliness of care.
Team-based care is crucial to boost availability, the report says.
"This could mean bringing additional nonphysician providers into the practice, as well as supporting nonphysicians in maximizing their scope of practice. By supporting clinicians such as nurse practitioners and physician assistants to practice to the 'top of their license,' practices may be able increase the number of available appointments."
Team-based care should be paired with patient education, the report says.
"Many individuals prefer to see a medical doctor instead of another type of practitioner, in some cases because they may believe that no other practitioner will have needed knowledge or skill to meet their care needs. Thus, practices, health plans, states, and national campaigns should educate consumers about the various types of qualified practitioners who are available."
Telehealth could help ease the shortage of specialists in rural areas, but there are challenges linked to telehealth in rural areas such as regulatory and licensing restrictions, the report says. For example, telehealth providers are often required to be in the same state as the patient.
To promote timeliness of appointments, the report says effective referral relationships and strong care coordination with referral sites are crucial.
To obtain healthcare service in rural areas, the report focuses on language interpretation, health information, health literacy, transportation, and physical accommodation.
For language interpretation, the report recommends interpreter services via phone or web-based platforms when interpreters are not available on-site.
Regarding health information, the report calls for better access to information from payers, particularly about providers who are in-network or out of network.
The report makes a pair of recommendations about improving health literacy: educating both patients and clinicians about the importance of patient engagement, and improving clinician-patient communication in general.
Transportation is one of the most daunting care access hurdles in rural areas. The report offers several recommendations to rise to the challenge:
- Establishing partnerships with transportation services such as taxis
- Contracting with bus services
- Hiring drivers
- Working with community partners such as nursing homes when conducting community needs assessments
- Leveraging paramedics and other community health workers
Total out-of-pocket costs and delayed care because of the inability to pay are the essential aspects of affordability for rural residents, the report says.
"The shift to higher deductible plans or other forms of underinsurance, lack of medical insurance, and network inadequacy are key factors that cause rural patients to delay care," the report says.
Healthcare providers can assist rural patients to afford care by helping them understand their insurance coverage, the report says. Providers can monitor the balances patients owe after insurance payments and increase literacy about insurance such as the financial consequences of picking a high-deductible health plan.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Telehealth can boost care access in rural areas but it has drawbacks such as regulatory and licensing restrictions.
A team-based approach to care can ease staffing shortages and increase access to care.
Options to address rural transportation deficiencies include contracting with bus services and leveraging health workers such as paramedics.