Several times a year, doctors, nurses, and other medical staff at Androscoggin Valley Hospital (AVH) in Berlin, New Hampshire, run through simulations of complications in the delivery of babies, including postpartum hemorrhage, placental abruption, and shoulder dystocia. The simulations are led by staff from Dartmouth Health, part of the Geisel School of Medicine.
Why does Dartmouth Health conduct simulations with an independent rural hospital that’s more than two hours from its main campus in Hanover? Because, as is true around the country, the academic health system (AHS) and the rural hospital need each other.
AVH delivers so few babies (about 80 a year) that its staff does not get much experience with critical pregnancy complications, says Natalie Valliere, RN, women’s services coordinator. Although AVH routinely plans for women with high-risk pregnancies to deliver at Dartmouth Health — which has the experience (over 1,000 deliveries a year) and resources to handle complications — the trainings provide benefits for patients and rural providers.
“We have to know how to deal with obstetric emergencies,” Valliere says. After all, Dartmouth Health is two-and-a-half hours away.
The program enables staff at AVH to handle more high-risk pregnancies, as well as routine pregnancies that develop complications, close to home — and therefore close to the mother’s family, other support networks, and personal physicians. “The best care is local care,” says Sam Shields, system vice president of strategy and regional operations for Dartmouth Health.
Local care also benefits the AHSs, which are often at or beyond capacity and therefore strained to accommodate patients from far away.
“If something happens that they [the rural hospital] can’t provide care for, the patients are going to come here,” says Lanier Lopez, MD, associate dean of graduate medical education at the University of New Mexico (UNM) School of Medicine.
Angela Still, MSN, RN, executive director for women’s services at ECU Health in North Carolina, the integrated primary health system associated with East Carolina University’s Brody School of Medicine, explains the basic strategy: “We want to provide high-risk care” at ECU but keep low-acuity care local when it’s safe and effective.
The need for AHSs to help rural hospitals is growing as these hospitals struggle financially. From 2005 through 2023, 146 rural hospitals closed or stopped providing inpatient services, according to the U.S. Department of Agriculture.
“We’re seeing more shrinkage of care in rural areas,” says Dodie McElmurray, RN, MSN, CEO of University and Community Hospitals at the University of Mississippi Medical Center (UMMC), which collaborates with rural hospitals outside of its system.
Recent budget cuts to Medicaid are projected to apply more economic pressure, because 1 in 4 adults in rural areas are covered under that federal insurance.
“We exist on razor-thin margins,” says Joseph Perras, MD, CEO of Cheshire Medical Center, a once-independent rural hospital in New Hampshire that became part of Dartmouth Health in 2015. “Hitching their wagons to a bigger health system becomes an existential issue for a lot of rural hospitals.”
Below are some of the ways that AHSs team with rural health providers to maintain high-quality care in those communities.
Resident placement
CHI Health Good Samaritan hospital in Kearney, Nebraska (236 beds), sits in a small city but is surrounded by rural communities. It can always use more doctors, and is getting them through a partnership with CHI Health and the Creighton University School of Medicine, which sits 180 miles away, in Omaha.
Each year, Creighton’s medical school matches four residents into its internal medicine Rural Track Program, which aims to acclimate resident physicians to rural health care while helping to alleviate the physician shortage in those underserved areas.
Eight rural track residents work at CHI Health Good Samaritan in Kearney; four more are training for 16 months in residency at CHI Health Creighton University Medical Center — Bergan Mercy, in Omaha, before moving to Kearney for the remaining 20 months of their residency, according to Jyotsna Ranga, MD, associate dean of graduate medical education at Creighton University.
“We want to extend our care to rural areas and recruit residents who want to work with rural populations,” Ranga says. “The benefit [to the local hospital] is that they have residents” to care for patients, while the longer-term hope is that some of those new doctors “will continue working in the community” after their residencies.
The same thinking is behind the Family Medicine residency program at the UNM School of Medicine, which each year sends two new residents to the 65-bed Northern Navajo Medical Center in Shiprock, on the Navajo Nation.
“Hopefully, you’re attracting people who want to work in [rural] communities,” says Lopez of the UNM School of Medicine.
That’s the case for Rutvij Patel, MD, a resident at Good Samaritan through the Creighton program. Patel, who grew up in a rural area of India, says the experience has solidified his commitment to practice in a rural area, probably Kearney.
“I was hoping to get more hands-on experience and to be part of a community,” Patel says of his motivation to enter the Rural Track Program. “Being part of the community has made me want to continue doing that. I feel that I’m doing something for the people.”
Some medical schools have programs in which students get part of their education at rural academic sites, such as the Wisconsin Academy for Rural Medicine at the University of Wisconsin School of Medicine and Public Health.
Electronic collaboration
Patients in the five-bed intensive care unit at Littleton Region Health Care, a hospital and medical center in rural New Hampshire, are monitored not only by the physicians and nurses on hand. Medical staff at Dartmouth Health, 60 miles away, are continuously monitoring the patients’ vital signs, plus conferring with local staff, says Shields.
“The staff just needs to hit a button and somebody [at Dartmouth Health] is there to assist with whatever they need,” Shields adds. “That’s allowing them [the rural hospital] to take on a higher level of care.”
In Mississippi, UMMC runs a similar collaboration with rural hospitals, as well as telehealth connections with emergency departments for consultations on critical issues that arise, McElmurray says. UMMC and some rural hospitals also share patient information through their electronic medical records system, which helps doctors at both facilities determine the best assessments for each patient, McElmurray says. The record sharing is particularly helpful, she notes, when a patient with critical needs will be transferred to UMMC, “so we have that knowledge about the patient already. It helps with the continuity of care.”
The electronic collaboration with rural health providers is not limited to hospitals. Atrium Health, which is affiliated with the Wake Forest University School of Medicine in Winston-Salem, North Carolina, provides pediatric consultations in schools for rural areas of North Carolina and Georgia. If a child has a physical or behavioral health issue, staff at the school can consult with an Atrium specialist via computer or phone to assess the child and determine the best course of action, says Brian Freeman, MHA, rural area president for Atrium Health’s North Carolina and Georgia division.
Parents can join the call from home or work, Freeman says. The next steps can include submitting a prescription to a local pharmacy or a referral to a specialist.
This process overcomes common barriers in getting access to care, Freeman says: “In the traditional model, the school calls Mom or Dad. The parent comes and gets the child, takes them to a pediatrician, if they can get an appointment. If they can’t get an appointment, they’re probably going to urgent care or to an ED [emergency department].”
Maternity care
When rural health leaders talk about where they need the most help, maternal care is often cited as issue No. 1.
“Obstetrics in rural environments are under threat,” partly because it’s difficult to maintain those expensive services at a high level of expertise with low volumes of patients, says Perras of Cheshire Medical Center in New Hampshire. “We are surrounded by small hospitals whose obstetrical services are at a high risk of closing.”
So AHSs around the country are helping to support maternity care in rural hospitals, largely by training local staff and sharing resources. Not only are outcomes better if deliveries are close to home, but carrying out more deliveries in local hospitals eases the demand on AHSs, says Still of ECU Health in North Carolina.
“Our labor and delivery unit does about 4,100 deliveries annually,” Still says. “We don’t have more room. It serves us to have those lower-risk deliveries in the community, closer to where those women live.”
That’s why ECU Health collaborates to support obstetrics staff at rural health facilities across more than two dozen counties, Still says. That includes staff training on such procedures as electronic fetal monitoring, advanced fetal life support, and emergency deliveries.
The trainings have elevated the skills of staff at CarolinaEast Health System, says Clinical Nurse Specialist Casey Toler, MSN. She says ECU staff come several times a year to train staff on various care techniques. The attendees include doctors, nurses, respiratory therapists, emergency department staff, and blood bank staff.
ECU even sponsors external-based classes on advanced life support in obstetrics, which cost $500 or more per person and include staff from CarolinaEast and other nearby hospitals. “We just don’t have that in the budget,” Toler says.
Clinical trials
A common struggle in clinical trials is recruiting a diverse array of patients from outside the urban hub of the AHS that’s running the trial. When patients must travel to the base site of the AHS — typically a large campus in a city — it puts an extra burden on those from outlying areas to obtain their treatments and assessments. For many needy patients, that suppresses access to cutting-edge care.
Atrium Health, which operates in several states, has expanded its clinical trials to be conducted in rural areas of North Carolina, Illinois, and Wisconsin. For example: Starting in 2021, it enrolled patients in cancer trials at Wake Forest Baptist Wilkes Medical Center, in rural Wilkes County, about 80 miles from its flagship hospital in Charlotte. Today, more than 20 patients are in that trial, according to Atrium Health.
“If that wasn’t there, the patient would have to drive to a tertiary care center an hour or a couple of hours away” for every trial appointment, says Freeman at Atrium Health. “By being a part of this academic health system, we can take the clinical trials to the patient.”
Mergers with rural hospitals
In a few cases, AHSs have absorbed rural hospitals into their systems through purchases and mergers. For example:
Cherokee Medical Center — a 60-bed hospital in a rural county of 25,000 in Alabama — went through a series of operators who weren’t able to make it financially stable. “The facility was at jeopardy of closing, which meant that [people in] the community would have to drive anywhere from an hour to three hours to the next available provider, depending on the care they needed,” Freeman says.
The hospital’s parent company, Floyd health system, merged with Atrium Health in 2021. As a result, Freeman says, “we’ve been able to stabilize that hospital.”
In New Hampshire, Dartmouth Health entered a joint operating agreement with Cheshire Medical Center in 1998, which became a health system member in 2015. Perras, the CEO of Cheshire Medical Center, says that partnership “ensures that Cheshire will continue to provide critical women’s health care in rural southwest New Hampshire.”
Others echo similar sentiments about the impact of collaborations between AHSs and rural facilities.
“It has really helped the staff feel more prepared. They feel more empowered,” says Valliere of AVH in New Hampshire. “It has been great to have all this education, and it trickles down to the patients.”
