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Reversing Rural Hospital Outmigration – Top 5 Ways to Help Rural Hospitals Thrive

Updated: May 3, 2022

In my last blog, I reviewed some sobering statistics Rural Health Solutions has found through researching how much of rural hospital’s primary care patient base has been lost over the last 5 years to urban areas. In studying 20 rural and critical access hospitals across the country, we found that the smallest amount of primary care outmigration from a Critical Access Hospital was 54%. The largest amount? 90%.

To reverse this outmigration and rapidly increase local community care, reimbursement, and patient engagement, we believe that effective patient recruitment, robust and well-designed ambulatory care coordination programs, intentional focus on the return of external transfers, and productivity-based surgical specialty programs represent the best opportunities to quickly reverse outmigration. Let’s review these key themes in detail.

1. You Have to Be Serious About Getting Your Patient Population Back – Active Patient Recruitment

A variety of Medicare care coordination activities require patient enrollment in the program before the clinic provider can provide the service. Most rural hospitals have little experience in conducting intentional outreach programs effectively. Website posts, You-Tube videos, billboards, or direct mail rarely influence patient or family decisions on choice of providers. To get patients back, you must be thinking about enrolling the entire Medicare patient population in your Primary Service Area zip codes, not just the patients who are in your EMR (reversing outmigration requires you gain patients, not just maintain your current patient population). So, think zip codes, not EMR as your Medicare recruitment catchment area.

Changing patient's approach to medical care generally requires direct patient conversation and an offer of a service that the patient desires or would benefit. Effective enrollment programs include a combination of call centers, text and emails and continue throughout the course of the year. Call center’s direct patient contact requires multiple attempts at patient contact, using well defined communication tools, supporting technology platforms and experienced staff. In many organizations, these technology systems and staff competencies are outsourced.

2. Annual Wellness Visits as the Gateway to Primary Care Remigration

The most effective outreach programs for gaining new Medicare patients involves contacting the patient directly and asking them to enroll in an Annual Wellness Visit (AWV). These programs can be completed by an Advanced Practitioner through a virtual visit, and include medication reconciliation, identification of prevention/wellness needs, and any other necessary care coordination. These patients are then referred into the clinic system for diagnostic testing and follow-up.

Interestingly, when comparing patient utilization patterns for those who receive an AWV versus those who have not, our research shows the AWV group have an increased number of outpatient clinic visits and a decrease in the both ED visits and hospitalizations. This decreased ED/hospital utilization is a desired outcome for Value-Based Care programs. And AWVs increase both the HEDIS Quality Score as well as CMS star rankings.

3. Managing Chronic Disease - Changing the Paradigm

The traditional approach to managing chronic disease is intermittent and episodic. Once a doctor makes a diagnosis, s/he schedules follow-up office visits on a routine basis, usually every four to six months. Most Americans are used to this cadence, but it makes no sense. Some patients with well-controlled chronic diseases might not need to see their doctor for a year, while others would benefit from monthly evaluations. But traveling to the doctor’s office once a month, often for nothing more than a blood-pressure check, is time-consuming, inconvenient, and for many people expensive.

Medicare billing requirements for Chronic Care Management require a 20-minute patient care contact each month to qualify for billing. Chronic Care Management programs do increase the number of patient “touches” per year. Yet, many of these programs have had very poor engagement scores from patients. As one senior told me, “this 20-minute phone call/month is like a purgatory for me and has to happen every month until I die. And it doesn’t make me healthier.” In fact, over the last 3 weeks, 3 CEOs told me that they were cancelling their for-profit programs due to the overwhelming negative reaction of these communication requirements from their community. Who would imagine that you could upset an entire local Medicare population by trying to improve patient’s long term survival?

But there is a much better way to address chronic disease that engages patients and their families than lengthy phone calls every month. The biggest difference in managing chronic disease is not better doctors or medications; the biggest difference is frequency of disease measurement and timeliness of treatment—factors facilitated by text- based regular patient self-reporting and monitoring, risk stratifying higher risk patients not improving, and taking early action on that patient group.

Chronic care management technology platforms now allow patients to be monitored at home and interact with their provider via automated text-based communications. Patient assessments of their disease process can be self-reported (last blood sugar, last weight, last BP,etc) or can be checked at home with a digitally connected devices to the electronic health record system.

The combination of text-based patient self-reporting and remote patient monitoring with standard wearable devices:

1) allows far more-frequent disease monitoring with automated escalation of patients needing more acute adjustments to a care provider for medication or treatment regimen changes;

2) provides faster and better disease control and fewer complications at a lower total cost;

3) increases immediate outpatient clinic patient referral evaluation to those who need it; and

4) creates a much higher degree of patient engagement by respecting patient’s time.

And there’s proof that this is a better way to provide care. With the combination of virtual visits and remote patient assessments and monitoring, Kaiser Permanente members in California and the mid-Atlantic region were found to be 14% less likely to die from stroke and 43% less likely to die from heart disease than the general US population.[1]

4. Focus on Getting Your Transfers Back

Transferring your patients to higher levels of care for specialized services from the inpatient areas or the ED is necessary for rural hospitals. What is unexpected is the skills that referral centers have in keeping these patients in their ecosystem after specialized care has been provided in their network. Specialized care followup begets primary care follow up begets other specialty referral. Soon, the patient is leaving is leaving the rural hospital ecosystem in the rearview mirror. For most rural healthcare leaders, the battle to preserve local community care is lost with nary a trace of the battle. And the losses continue to multiply, day after day, week after week, until leadership realize one day the how sizeable the local community's losses actually are.

To change this all too familiar outmigration, rural hospitals need to understand the stakes and the threats of transferring patients to specialized facilities. The first remigration strategy is to explain to the patient and their family, before they are transferred, what is going to happen and identify a patient/family representative that the case manager can communicate with daily during the patient's stay at the referral site.

Communication with the patient's case manager at the referral hospital is also necessary to explain the plan to repatriate the patient back to the rural hospital for the last 1-2 days of the patient's stay so that local resources can be put in place to ensure the patient's recovery. Critical Access Hospitals have the additional unique capability of swing bed management of the patient that referring facilities are often unaware. The rural hospital case manager must also ensure the transportation back to the local hospital.

For patients with less than 3 day length of stay, the focus of Transition Care Management is to first conduct a follow up call in 3 days to assess patient progression and perform a medication reconciliation. Patients should then be seen in the clinic for face to face meeting within 7 days of discharge. The Case Manager has to own this coordination of care activities.

Active transition care mangement for ED/hospital transfers to specialty hospitals therefore starts before the patient is transferred, daily communication with the patient/family representative and case manager while at specialty hospital, and an organized plan to either repatriate the patient back to the rural hospital for the last 1-2 days prior to patient discharge or ensure 3 and 7 day follow up.

5. Building General and Surgical Specialty Service Practices in Rural Hospitals – The Right Way

67% of average hospital net revenue comes from surgery programs. For Critical Access Hospitals, Medicare Cost Reports also allows these hospitals to be reimbursed for costs of surgical and cardiovascular implants. And every rural CEO knows that.

Rural CEOs have the right idea for building out their surgical specialties. However, CEOs are chagrined when they try to find surgical capability solutions for their hospitals based on the way that these organizations stack the risk of growing the practice against the rural hospitals.

Most of the surgical staffing companies who provide these services require the hospital to absorb the financial risk of filling the surgeons time on the day they are hired to come to the hospital or clinic. If no appointments are scheduled, the surgeon is still paid their rate. Think of this as the "hired-gun" surgeon model.

Historical problems with these programs centers around the interests and alignment of the surgeon to the hospital. This type arrangements places all the risk for the surgical specialty growth and success on the hospital – not the surgeon.

Requiring the hospital to develop the referral base for these surgical specialties is not in the hospital’s best interest. The hospital core competency is not building a surgeon’s practice.

Effective rural surgical specialty program models require the surgeon, not the hospital, to be responsible for building out their own referral base in the local community. The regular practice building for a surgeon requires time and efforts and takes months to build. The surgeon communicates with each of the local providers explaining their expertise, the types of patients they see, and provide feedback to referring provider.

Even if the provider is only onsite 2 days a month, the surgeon still needs to build their surgical practice. In this model, the surgeon compensation is production based – meaning if the provider cannot grow their rural practice, they will not be successful. This risk-based compensation model closely aligns with the interests of the hospital leadership to grow these surgical specialty practices.

Active Medicare patient recruitment for Annual Wellness Visits, Chronic Care Management programs that uses text-based patient reporting with remote patient monitoring, rather than 20-minute monthly phone calls, active transitional care management programs, and productivity-based surgeons who grow their local rural practice part time all present significant opportunities for rural hospital leadership to reverse their outmigration. Without taking concrete steps to address these threats, rural hospitals face the peril of continued loss of their market.

For more information about how these services can help you, contact Rural Health Solutions at

Rural Health Solutions (RHS)

RHS has over 30 years of experience working with more than 200 hospitals and ambulatory care organizations across North America to improve staffing, patient access, operating margins, quality of care and patient experience. RHS provides solutions to our client unaffiliated rural hospitals. Learn how RHS has helped other rural hospitals increase their long-term financial viability at or contact us at

[1] . Pearl R, Wayling B. (May 1, 2022), The Telehealth Era Is Just Beginning. Harvard Business Review,

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