From staffing woes to financial struggles, the COVID-19 pandemic has exacerbated an already fragile environment for rural hospitals. A recent report from the Chartis Center for Rural Health suggested that 46% of rural hospitals are contending with negative operating margins. Modern Healthcare Managing Editor Matthew Weinstock spoke with Patricia Schou, executive director of the Illinois Critical Access Hospital Network and immediate past president of the National Rural Health Association, to talk about the long-term needs facing rural providers, as well as challenges they’re experiencing on the COVID-19 vaccination front.
MH: We’re seeing some states start to really loosen their COVID restrictions, including no masking or social distancing. What are you hearing from your colleagues in rural hospitals and their concerns about potential spikes in cases?
Schou: We still have concerns because these infection-control measures still have to be in place until we get people vaccinated. I’m no different than anybody else. We want to go back to the way life was, but we have to remember that we still have elderly people and people with multiple comorbidities who are still exposed.
It’s a challenge particularly for states like Illinois, where I’m from. We have border states that have lesser restrictions than we do. So it becomes a challenge for those hospitals and areas around the borders. Do we have these restrictions? Do we not have restrictions? Then it’s a mixed message for people.
MH: How are rural providers contending with both vaccine hesitancy as well as the supply of vaccines?
Schou: With the vaccine for healthcare staff, it’s a little bit all over the place. It’s about 50% to 60% of the staff have taken the vaccine. The ages between 20 and 40, particularly in the female population, are reluctant. They’re a little nervous about fertility and the impact of that for childbearing. Not that they’re really against the vaccine; they’re not quite sure. Then you have people who have had COVID and had that exposure, and they’re waiting for the (recommended) 90 days to (pass before getting vaccinated). And then some people have stepped back because they think, “Well, let somebody else go for it that might need it.”
As far as the community vaccine, we can’t have it fast enough. There are delays within smaller communities because of getting it out. (Vaccine centers in those areas have) to work through the health departments and each state is different. And we have vaccines going out federally to pharmacies—the Walmarts, Hy-Vees, Walgreens—and they’re getting their vaccines pretty regularly. But it’s just all over the place. It’s inconsistent.
And we are seeing a few people who aren’t coming back for their second vaccine, and that concerns us, whether it’s a transportation issue or a concern or whatever.
Maybe the Johnson & Johnson vaccine will be easier. We don’t know, but we’re excited about the three different vaccines being available. And particularly the one dose. I had one hospital CEO share with me—and it’s no different than colleagues across the country—that, “If we have plenty of vaccine in the near future, if somebody comes in as an inpatient and they haven’t been able to vaccinate, we can get them vaccinated. We don’t have to call them back.”
MH: We are a year into the pandemic. The workforce across the board has been stressed. Rural hospitals already had challenges being able to staff up. How are rural providers addressing staffing issues, especially as we see some light at the end of the tunnel?
Schou: It has truly been one of the biggest challenges. Think about the hospital CEOs and the finance people trying to budget—how much staff do you need and so forth moving forward? Step back into the fall when we had that second outbreak. It was a very difficult time because we couldn’t find enough staff to fill the gaps. Rural hospitals were calling agencies and they were wanting $150 to $175 an hour for a nurse. That’s not sustainable.
In Illinois and across other areas, they’ve had to be somewhat creative. Offering staff a little extra bonus if they would pick up an extra shift and trying to work within the system. They just couldn’t compete with the staffing agencies. And we had trouble with transferring patients. We had patients in our rural hospitals who needed to go to tertiary care, not necessarily for COVID, but for other situations (like cardiac care). And those tertiary-care centers … had staffing issues. They couldn’t take our patients.
We got through it through patchwork, but long term, we’re going to have to really beef up our healthcare professionals … there’s a constant push for workforce development. But sometimes with rural, you’re down the road there and the training is done in larger facilities. So we have to build that connection early on to get people to come back. We can pay somewhat competitively, but we couldn’t pay those agency prices there for a while.
MH: The latest federal COVID relief effort includes some money for rural providers, but that’s a short-term patch. Looking past the pandemic, what needs to change to keep rural hospitals viable?
Schou: There’s a number of things that we learned from COVID. One is that telehealth is going to have a great influence. I think it opens the door for specialty care and keeping some things local, but it also opens up competition. So how do you compete and keep people locally?
Hospitals have to rethink their strategic plans. If you did a strategic plan two years ago, you should be rethinking it and look at what you can deliver for the future. We have to be creative as rural hospitals. We can’t rest on what’s been done before and we have to look at how we take advantage of technology. How do we get better at care coordination? One thing that happened during COVID is many of our small hospitals built good working relationships with their larger tertiary-care centers. They sent patients there and the tertiary centers no longer could care for a COVID patient and they sent them back to the rural hospitals, to their swing-bed programs. We were able to better utilize beds and delivery of services. If we can build on those things, we can start to make hospitals more viable.
The other thing … (is) stimulus for rural communities because it’s not only the hospitals have to be creative. We also have to have jobs and places to live. And I’d like to say, rural might be the new place to come and live because we have great schools and housing and things like that. But in a rural community, you have to have a good workforce, you have to have good healthcare and good school systems. So they all go hand in hand.