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    Rural and at risk for COVID-19

    In remote regions where patients are poorer, sicker, and older, the coronavirus pandemic is hitting many communities hard. Here's how medical schools and teaching hospitals are stepping up to help.

    The University of Mississippi Medical Center has collaborated with the state department of health to run nearly 50 COVID-19 testing sites in rural communities
    The University of Mississippi Medical Center has collaborated with the state department of health to run nearly 50 COVID-19 testing sites in rural communities.
    Courtesy: University of Mississippi Medical Center

    Newport, Washington, is gorgeous. It’s full of huge pine trees and mountains that stretch up 5,000 feet, says Geoff Jones, MD, a family medicine doctor in the town of 2,000. It has a lake and river and quiet streets without a single stoplight.

    But, like so many rural communities, it also ranks high in unemployment, mental health issues, and serious health conditions — all of which are inflamed by the current coronavirus outbreak.

    “So many parts of the town fabric are just gone because of COVID-19. Schools, churches, and sporting events are all closed. There’s been a lot of increased anxiety and depression,” says Jones. “Also, people are afraid to come into the clinic, and this is exacerbating their chronic conditions every day.”

    So far, Jones says, his community has been relatively lucky, experiencing only a handful of cases of COVID-19. He attributes that partly to social distancing and partly to guidance he’s received from the University of Washington (UW) School of Medicine, where he is an assistant clinical dean. “I learned from the UW Medical Center’s response as COVID broke in Seattle. So, we were able to set policies on how to prevent spread in the clinic long before the virus eventually made its way out here.”

    In the early days of the coronavirus pandemic, rural America seemed relatively safe because of the social distancing that’s a natural feature of remote landscapes. Now, though, more than 85% of nonmetropolitan counties report COVID-19 patients, and cases are growing rapidly in some spots. At the end of April, almost one-third of counties reporting a high prevalence of infections for the first time were rural or smaller communities.

    That’s particularly worrisome given that people in rural areas tend to be older and sicker — and therefore more likely to require hospitalization if they contract the disease. In addition, care can be tough to get. Approximately 120 rural hospitals have closed in the past decade, and rural facilities have far fewer intensive care unit (ICU) beds per capita than metropolitan areas.

    “As the only academic medical center in Arkansas, we feel a responsibility for all 75 counties. … This is part of our DNA. This is part of what we are here to do.”

    Cam Patterson, MD, MBA
    University of Arkansas for Medical Sciences

    All this means medical schools and teaching hospitals have needed to figure out how best to support their rural patients and remote colleagues during these difficult times. They’ve been working quickly to establish testing sites, educate patients and physicians, and provide essential care.

    “As the only academic medical center in Arkansas, we feel a responsibility for all 75 counties,” says Cam Patterson, MD, MBA, chancellor of the University of Arkansas for Medical Sciences (UAMS). “There are so many complex challenges from this pandemic, including how to get care to people who live 30 minutes from the nearest paved road.” Still, Patterson says, “This is part of our DNA. This is part of what we are here to do.”

    Passing the testing test

    In early March, there were no reported COVID-19 cases in Tennessee. Two weeks later, there were 70. As elsewhere in rural regions, leaders at East Tennessee State University (ETSU) Health knew they needed to set up testing facilities — and fast.

    Within days, ETSU crafted dozens of essential processes, from screening criteria to drive-up traffic flows, and launched the region's first testing site.

    Our chief medical officer, dean, and others came together quickly to figure out what was needed, and an infectious disease specialist on our faculty was able to make the testing process more nimble,” says Beth Fox, MD, MPH, associate dean of ETSU James H. Quillen College of Medicine. Ultimately, the ETSU system became the model that the state’s department of health and a regional health care system used to build more than a dozen other testing sites.

    In Mississippi, the University of Mississippi Medical Center (UMMC) created an online scheduling app and collaborated with the state department of health to provide more than 50 rural testing sites. Meanwhile, at UAMS, leaders decided to take testing on the road. “We just loaded everything into a van and rode off,” says Jennifer Hunt, MD, chair of the Department of Pathology and Laboratory Services.

    “We’re not always well-known to the community, so partnering makes [testing] more trustworthy. It makes a big difference when someone sees the mayor’s daughter at the entrance.”

    Jennifer Hunt, MD
    University of Arkansas for Medical Sciences

    The UAMS mobile testing unit — which so far has screened 1,100 people at 13 sites — hauls iPads, personal protective equipment, and numerous other items staff may need. “We always end up providing some primary care because we may be the only doctor people see,” Hunt notes. The crew of eight or nine even includes a social worker in case patients need help finding a place to quarantine.

    Still, communities also need to provide local volunteers, explains Hunt. “We’re not always well-known to the community, so partnering makes the whole thing more trustworthy,” she says. “It makes a big difference when someone sees the mayor’s daughter at the entrance.”

    Moving COVID-19 patients

    Sometimes, patients in rural areas who test positive for COVID-19 may just need some basic monitoring. At other times, sicker patients need to move to a larger hospital because local facilities may have no ICU beds, no emergency care specialists, or little experience dealing with complex infectious diseases.

    Since the outbreak, UAMS has transferred roughly 50 COVID-19 patients from smaller facilities to its hospital, says Patterson. “We had worked hard to set up relationships for smooth transfers under normal circumstances, so that has made it a lot easier for us to do the same things in extraordinary circumstances,” he says.

    In Mississippi, UMMC recently helped create a five-tiered triage system that determines which patients get treated in which facilities. When local staff believe a patient needs to move, they contact UMMC’s Mississippi Center for Emergency Services — part of the state’s disaster response system — which identifies the appropriate hospital and organizes the transfer.

    Usually, the move happens via the local hospital’s ambulance service, and only rarely does it occur via helicopter transfer, explains Jonathan Wilson, PhD, RN, UMMC chief administrative officer. “The rotor [spin] of a helicopter could aerosolize droplets from the patient,” he says. “That poses a risk to everyone around.”

    If someone needs close monitoring from UMMC providers during transfer, the providers can fly to the remote location and then accompany the patient back in UMMC’s negative pressure ambulance, which pulls airborne droplets into a special filter. “Our goal is to keep everyone as protected from risk as possible,” Wilson says.

    In addition, UMMC sometimes helps transfer COVID-19 patients in the other direction, away from larger hospitals. These patients are recuperating but can’t head home for a variety of reasons, such as that someone there is immunocompromised or that they simply don’t have a home.

    “A rural hospital often can provide services below the level of acute care, acting as a sort of nursing home or shelter, which helps solve some of the statewide capacity problems,” notes Wilson. In its first week of implementation, the center has moved about a dozen convalescing patients to rural hospitals.

    Providing care from afar

    Not all rural COVID-19 patients need to be transferred, however. And sometimes, patients deteriorate so rapidly that moving them isn’t an option. In those cases, academic medical centers can lend their expertise remotely, says Matt Lyon, MD, Augusta University Health medical director for telemedicine.

    In fact, several times a week since the start of the outbreak, members of Lyon’s team have helped rural providers intubate patients via sophisticated telemedicine technologies. “We can see the view right inside the patient through the intubation device because of a small video camera in it,” Lyon says. “We can observe and help guide physicians through the procedure so they know they're doing it correctly. It’s quite amazing.”

    Even when such complex procedures aren’t key to care, telemedicine has allowed teaching hospitals to support rural communities during the outbreak.

    Soon after the pandemic hit, Dartmouth-Hitchcock Health increased its remote services dramatically, expanding from fewer than 10 daily telemedicine sessions to more than 2,000 per day across five states. A significant portion of these new visits are direct-to-patient appointments meant to keep potentially infected individuals away from clinics, while others are provider-to-provider consultations that allow COVID-19 patients to get care closer to home.

    “We can see the view right inside the patient through the intubation device because of a small video camera in it.”

    Matt Lyon, MD
    Augusta University Health

    “We wanted to keep people local. In a rural area, the main medical center is sometimes the biggest building someone has ever been in. They can be much more comfortable in their own community,” says Mary Oseid, Dartmouth-Hitchcock executive vice president for regional strategy and operations.

    Telehealth took root quickly in other rural areas as well. Newport Hospital & Health Services built an entire telemedicine system in a matter of days thanks to guidance from UW’s medical school, UW Medicine's Project ECHO telementoring program, and others.

    Jones experienced its usefulness early on. “There was an older woman whose chronic lung disease was getting much worse, but she was terrified to come into the office. We asked a neighbor to bring her a cell phone for a virtual visit,” he says. “We adjusted her meds and managed to keep her out of the hospital. She’s doing fine now.”

    The power of knowledge

    Leaders of academic medical institutions also understand that, during a pandemic, knowledge isn’t just power — it also can be a matter of life and death.

    Douglas Patten, MD, associate dean of the Medical College of Georgia (MCG) at Augusta University, is one such leader. He lives in Terrell County, Georgia, a poor and largely African American area that lost more than 20 people to the pandemic in a matter of weeks. That number reflects a death rate higher than that of New York City.

    Each day, Patten works to provide the local hospital system, Phoebe Putney, with essential information. As a member of the steering committee there, he monitors COVID-19-related research to help shape clinical guidance. “There’s literally dozens of articles per day,” he says. “These providers haven’t ever had to deal with anything like this, and if we can create standardized pathways for them to follow, they can make sure they are taking the right steps with the right patients.”

    In Mississippi, a great deal of provider guidance comes from UMMC’s Mississippi Center for Emergency Services, which answers questions 24/7 from hospitals across the state. UMMC also has worked with the health department to disseminate information on such crucial issues as how to triage possible COVID-19 patients in emergency departments.

    Meanwhile, academic medical centers elsewhere are providing rural residents with vital information to help them stay healthy.

    The University of Minnesota Medical School (UMMS), for example, has taken to the airways, co-creating a weekly COVID-19-related public television call-in show that reaches roughly 50,000 people. “Our faculty members cover everything from how to use a mask to how long it will take a vaccine to get here,” says Paula Termuhlen, MD, dean of the UMMS Duluth campus. The show is important given that rural areas often lack reliable Internet and local newspapers have been closing or publishing less frequently, she notes. “We’re filling a real gap.”

    “We must do all we can to help these communities that were already struggling and have been hit so hard.”

    Douglas Patten, MD
    Medical College of Georgia at Augusta University

    In southwest Georgia, Patten has been educating people about the crucial role of masks and social distancing. “The shelter in place orders came at a time when people were not quite ready to embrace them,” he says. Patten is grateful that his presentations to churches, schools, and grassroots groups have had some impact, and he and his colleagues remain committed to helping. “We must do all we can to help these communities that were already struggling and have been hit so hard," he says.