CHA playbook aims to restructure rural health care delivery

On Dec. 1st, the Colorado Hospital Association (CHA) released a playbook that lays out a framework for health care systems to provide better health care to rural communities. Using interviews with more than 30 rural health leaders, a literature review, and rural health care data, the playbook offers tools for improving health care coverage for rural communities that have been disproportionately impacted by the COVID-19 pandemic.



As part of the playbook, CHA designed an Assessment Tool for health care leaders to assess the effectiveness of their communities’ systems and to offer rural health care delivery systems a way to strategically change how they operate. The playbook describes the tool as an “honest look in the mirror” for organizations rather than a mandate to change how they function. It also encourages sharing of the tool’s information with other health care systems.

The playbook suggests that a convention of board members, administrative/clinical leaders, frontline workers, local citizens, and others from rural health organizations complete the assessment. It recommends the organizations’ senior leadership teams then review the completed assessment.

The assessment includes questions for the group to complete related to five issues that often impact the efficiency and effectiveness of rural health organizations. These include:

  • Governance and Leadership: Evaluate organizational leadership and reflect on the diversity, effectiveness, and accountability of senior leadership teams.
  • Community Engagement: Ensure the organization is engaging with and meeting the needs of their community.
  • Financial Health: Assess financial efficiency and capacity to deliver value-based care.
  • Clinical Care: Ensure organizations are actively trying to make quality care more accessible.
  • Emergency Preparedness and Resilience: Test readiness to respond to emergencies and disasters such as emerging infectious diseases and natural disasters.

Rural communities face unique health challenges as a result of their location, the playbook says. These include limited broadband access, an abundance of jobs in which social distancing is difficult (primarily agriculture), greater commercial interdependence, significant mental health issues, less availability of health providers, and a higher rate of uninsured people.

The playbook identifies nine challenge areas often faced by rural health systems. For each one, the playbook lists practical guidance and questions to help organizations navigate the challenge.

The challenges include:

Clinical Care: Rural health systems must confront issues like limited facilities, staffing shortages, and an increased reliance on telehealth due to COVID-19. Solutions offered by the playbook include practicing general sanitation and wearing masks, using telemedicine when possible, postponing elective surgeries, and screening everyone who enters a facility.

Communication: Clear and consistent communication is essential to a well-functioning health system. It is important that rural residents receive tailored messages from health officials that accurately inform them about their health care options. Organizations should not rely solely on local data because this may mask local hot spots and should be conscious of local health literacy levels.

Community: Rural communities have health difficulties urban communities do not, including a higher percentage of people over 65, less ability to shelter-in-place due to communal interdependence, and scant broadband access. Mitigation strategies to address these issues include building upon local infrastructure to mount a response, anticipating the needs of vulnerable populations, and mitigating the spread of the disease through community guidance.

Cross-System Communication: Pre-existing community partnerships are crucial in ensuring cross-sector cooperation. Some ways to achieve effective cross-system communication are lean organizational structures, interconnected data systems, and the willingness to share funds and supplies across systems.

Space: COVID-19 has strained rural facilities’ already-limited capacity levels. Re-engineering clinical space is critical in accommodating increased capacity demands. Space utilization recommendations include designating one entrance of a facility for COVID-19 positive patients, placing physical distance markers in crowded areas, designing a way for testing or exams to occur outside of the facility, and identifying alternative sites to house residents (such as hotels or gymnasiums).

Spending: Rural health systems face financial hardships because of revenue loss due to low in-patient levels, workforce shortages, increasing operating expenses and more. Ways to improve cash flow include regularly evaluating service lines to anticipate changing needs, monitoring financial parameters closely, and cutting unnecessary expenses if possible. Medicaid expansion would provide facilities with supplemental funding and help prevent closures.

Staffing: Rural health systems experienced significant staffing issues prior to the pandemic. Potential new staff are discouraged from working in these facilities because of their lack of resources. Facilities often lack employees with expertise in certain areas and require staff to function in multiple roles. COVID-19 only intensified the staffing problem. Mitigation strategies include ensuring the well-being of staff (informing them about PPE availability, providing them with adequate testing, etc.) and having effective surge planning by collaborating with other local health facilities.

Statistics and Surveillance: Surveillance and risk assessment of rural communities are important, and the playbook recommends consulting resources like the Social Vulnerability Index and COVID-19 Preparedness Scores. COVID-19 tests are scarce in rural communities — as of mid-June, over 60% of rural counties did not have a testing site, according to the playbook. Strategies for operating testing sites include providing drive-through testing, expanding in-house testing abilities, and considering the use of alternative staffing arrangements for testing sites. 

Supplies: Rural facilities are often short on supplies due to limited funding. Ways to increase availability of supplies include borrowing ventilators from nearby facilities, using alternative supply chains for PPE, and partnering with communities to produce PPE locally. Organizations can accept PPE donations from the community and utilize the state’s PPE Marketplace.