While many states have faced rural hospital closures due to financial issues, Utah has not had any since 2005. Despite this, Utah’s rural healthcare system still struggles with staff shortages and a lack of resources. Experts discussed these challenges at the 2024 Utah State of Reform Health Policy Conference last month.
Dr. Matthew McCullough, rural hospital improvement director at the Utah Hospital Association, said a primary challenge rural hospitals face is that they care for an older, sicker, and poorer population, which affects how they are paid. Rural Utahns are also less likely to have insurance compared to Utahns in the urban counties.
Rural hospitals continue to struggle with workforce issues, McCullough said. Hospital emergency rooms are often overwhelmed with patients experiencing mental health crises due to a lack of behavioral health professionals.
With a growing need for nurses in Utah, some employers are looking to hire travel nurses to fill the gaps. However, travel nurses are expensive to hire, McCullough said, and they often cannot find affordable housing in rural areas.
McCullough highlighted Beaver Valley Hospital as an example of a rural hospital that has successfully maintained its workforce. He said the hospital has never had to focus on recruitment efforts because the hospital’s workforce has grown through local workers from within the community. The hospital provides funding for high school level health sciences classes, as well as funding for students to go to college and get training.
McCullough also discussed the overall health of rural hospitals. He said most of his time is spent supporting the nine independent rural hospitals in the state so they remain financially strong. While the state’s hospitals face significant challenges, most of them are doing very well, he said.
“A lot of them are doing improvement projects, expanding service lines,” McCullogh said. “A lot of them have built new women’s centers. They’re keeping their obstetrics (OB) services.”
McCullough said independent hospitals work with the hospital system to ensure success. Rural hospitals collaborate with University of Utah Health and Intermountain Health to offer specialty telehealth services such as stroke care, burn care, oncology, neonatal intensive care, and more.
Marc Watterson, director of primary care and rural health at the Utah Department of Health and Human Services (DHHS), said the smaller workforce in the rural healthcare system comes with a unique set of challenges.
“[Workforce shortages] require our individuals in rural communities to really try and be a jack-of-all-trades because there is so much need and so few providers.”
— Watterson
Watterson discussed a family nurse practitioner who was working in a rural Utah county and provides care for people of all ages.
Even in situations when she was unable to provide specialty care, Watterson said the nurse practitioner was able to act as an intermediary between her patients and specialty providers in urban areas to keep the patient in their community. She told Watterson that if she wasn’t there, she worried some patients would have gone untreated.
“You start to see how, in our rural communities because we have shortages of providers, it plays into a number of different things,” Watterson said.
Dr. Keith Horwood, a physician at Community Health Centers (CHC) Utah, said staffing in rural areas requires training in those areas. People tend to practice medicine where they train, he said, noting his training experience as an example.
“The closer you can keep people to training in place, the higher the probability that you get them to stay in place when [they’re] done. I [initially] said, ‘Oh no, I am leaving Utah as soon as I’m done,’ and here I am 35 years later and really loving it.”
— Horwood
CHC has programs that help people gain the necessary skills to be successful in rural medicine, Horwood said. A program that began in 1999 allowed CHC to start sponsoring and teaching advanced skill sets to family medicine doctors. The doctors learn surgical and advanced OB skills after their three-year residency.
Beginning next year, CHC will also have a residency program for people interested in practicing medicine in the rural Intermountain West, Horwood said.
It is also important to ensure hospitals and clinics help providers support the needs of their families, Horwood said, as providers often leave rural communities because their spouse or family is not happy there.
Dr. Stephanie Lyden, vascular neurologist and faculty director of Rural Underserved Utah Training Experience (RUUTE) and regional affairs at University of Utah Health, said RUUTE’s goal is to get medical students on rotation in rural areas throughout Utah and the Intermountain West.
RUUTE operates many programs aiming to interest students in practicing medicine in rural areas, including the Community Engagement Experience.
“We have students learning how to do a needs assessment, then traveling to a rural area where they work with a rural preceptor for about four weeks. And then they have to come up with an intervention to address a health need,” Lyden said.
Lyden said RUUTE also has a K-12 pipeline program called Little RUUTEs—which aims to get rural and underserved students interested in health sciences—as well as programs for undergraduates and medical students.
Watterson discussed a variety of workforce development programs run by DHHS, including a loan repayment program, primary care grants, and the Conrad State 30/J-1 Visa Waiver Program, which allows non-citizen doctors who received their medical degree in the U.S. to return to the state and practice medicine. These doctors are often specialists, he said.
The agency also offers funding opportunities for providers looking to start clinics in rural Utah. Watterson highlighted two of these clinics in Beaver and Hildale, which are both run by people who grew up in those areas. Their providers are trusted because they come from the communities where they practice, he said.
“Because it’s an individual who grew up in the community that is now providing the care, they’re seeing hundreds of individuals that would have never approached their clinic,” Watterson said.
Watterson said the programs draw from both federal and state funds to attract rural workers. The programs require providers to report certain metrics in order to ensure responsible spending of taxpayer dollars, he said.
Telehealth could help relieve some of the challenges rural hospitals face. McCullough discussed two types of telehealth services: provider consultation for specialty care and direct-to-patient care. He said rural hospitals have used consultation telehealth services for a while, but rural areas do not use direct-to-patient telehealth services as often.
“In my experience, [direct-to-patient telehealth] grew more in urban areas than it did in rural areas, even through COVID, which is kind of counterintuitive,” McCullough said.
Telehealth costs money to implement because it requires more staffing and infrastructure, McCullough said.
Lyden said many people cannot afford the necessary technology to receive telecare in their homes, and may not have reliable broadband access, so rural communities need to consider different ways to offer those services to residents.
“Having these community health centers where [rural residents] can go, or even a library [can help],” Lyden said. “There has been work [done] looking into libraries that have private rooms set aside where patients can receive a telehealth visit.”
Lyden also highlighted the university’s telestroke program, which has 24-hour, on-call neurologists available for rural hospitals to consult with if they do not have a neurologist in their area.
Horwood said telehealth consult services within a rural healthcare system allow people to stay in their community.
Lyden said there are now more options for billing patients for telehealth services available through Medicaid, and that policy changes can continue to help improve the telehealth system.