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Conversations surrounding rural health are more important now than ever. Our communities are changing at a rapid rate – in many cases, faster than our willingness to redefine healthcare. As the needs and preferences within our communities rapidly change over the next decade, many leaders will be forced to consider how they can define an economic structure that systematically incentivizes a culture of health.
According to a 2023 survey conducted by JLL, twenty-two percent of surveyed respondents did not seek medical care within the last year. What this survey also showed is that access challenges were not evenly distributed: rural patients were less likely to have accessed care than their counterparts. When people cannot access care appropriately, this leads to worsened healthcare inequalities and clinical outcomes.
To compound the issue of healthcare access, 30% of all rural hospitals in the country are at risk of closing. Rural hospitals are at risk due to losses on patient services and low financial reserves. In over half of the states, 25% or more of the rural hospitals are closing and in eight states, the majority of rural hospitals will be at risk. For many communities, the closure of a hospital cannot mean the termination of healthcare – making the discussion of sustainable access to care within rural America the most important conversation in generations.
Rural Emergency Hospital Designation
To address the loss of essential healthcare services in rural areas due to hospital closures, Congress established the Rural Emergency Hospital (REH) designation in December 2020 as part of the Consolidated Appropriations Act. The REH designation is designed to maintain access to emergency outpatient hospital services in communities that may not be able to support or sustain a Critical Access Hospital or small rural hospital.
Prior research attempted to estimate the number of rural hospitals that would consider converting to the REH. They applied three measures to predict that 68 hospitals would potentially convert to be an REH. These measures include three years negative total margin, average daily census (ADC) less than three, and net patient revenue less than $20 million. They also looked at the characteristics of rural hospitals that have low-volume emergency departments (EDs) that may seek to convert to REH. Compared to hospitals with high-volume EDs, these low ED volume facilities were more likely to be government owned, have a low average daily census, and have a rural health clinic.
Current modeling shows that the potential number of conversions is nearing 100 hospitals. In the past six months, over 300 facilities have sought out information from the Rural Health Redesign Center, a 501(c)(3) nonprofit that has been appointed to serve as the national Rural Emergency Hospital Technical Assistance Center. As of May 2024, 28 facilities have converted to a REH – with over half of the converted facilities being located in Texas, Arkansas, and Mississippi.
Looking Ahead
Rural Emergency Hospital is the only new CMS hospital designation in the past 20 years. While it may hold promise to enable rural communities to move towards reimagining care delivery for their residents, as with many other reform activities, the initial design and requirements may need modification to fully address the needs of rural communities.
Swing beds are a critical source of care delivery in rural communities for post-acute and rehab needs not often available through other providers. In addition to swing-bed care, rural hospitals often provide other types of care, such as behavioral health services in distinct part units that the REH is not allowed to own. Other concerns raised by hospitals include the loss of 340-B drug program revenue, Medicare Advantage and Medicaid reimbursement practices for the REH services, The inability of some CAHs with necessary provider status to convert back to this designation if REH proves to be an unsustainable path post-conversion.
Additional concerns voiced regarding conversion to REH include the passing of state specific facility licensing and payment rules that address mandatory staffing requirements and state payment subsidies that may no longer be available to the REH.
Best Practices Moving Forward
As architects and designers work with rural healthcare systems, adaptation will be critical. By understanding the emergency healthcare challenges rural communities face, the industry can begin to adapt successful strategies that have been implemented to combat these issues. By embracing new processes, design environments can enrich the patient experience and create a model of sustainability.
Article by: Andrew Mitchell, AIA, ACHA
