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Rural Hospitals Face Their Most Significant Battle For Survival: Primary Care Outmigration

Updated: Jun 15, 2022

Rural hospitals are an essential part of the American healthcare system and provide services from primary care to long-term care all across rural America. Rural communities depend on them for convenient access to care. The pandemic demonstrated the striking reality of rural hospitals critical function as safety nets when tertiary hospitals were overwhelmed with the demand for services. But the threats to rural hospital survival are real.

While they are considered a central part of most rural communities, too many are struggling. According to the North Carolina Rural Health Research Program, 138 rural hospitals closed between January 2010 and February 2022. This is an alarming figure, but why is it happening?


Low reimbursement rates, increased regulation, reduced patient volumes, and uncompensated care cause many rural hospitals to struggle financially. Adding to this are decreasing rural populations, an increase in uninsured patients, difficulties in recruiting providers and nurses, equipment underuse, and changing reimbursement regulations.

Another key factor is something called “out-migration,” which is the outflow of patients to larger tertiary medical centers that are often far from rural communities and often at a great inconvenience to both families and patients. These far-away tertiary hospitals are usually regional centers of excellence that offer more specialization, more sophistication, better technologies, and many more services.

With smaller facilities having less technical capabilities and specialized services, specialized care outmigration to larger organizations is an expected outcome. But far more threatening to the long-term survival of rural hospitals is the significant amount of primary care outmigration that has been occurring for at least the last 10 years.


RHS analysis of more than 20 Critical Access Hospitals shows that over the last 7 years that all 20 hospitals had lost at least 50% of their primary care services to urban hospitals outside their primary service areas. With increasing primary care outmigration, shrinking rural populations and an increasingly elder population, many rural hospitals face an increasingly bleak battle for survival.

During one of our recent conversations with a Board Member of a rural hospital, he complained that the hospital leadership was simply focused on “defense” planning how to slow down the loss of their patients to tertiary hospitals who have continued to outflank their organization in providing services and increasing their outreach to their rural community. He believed that they were simply outgunned. After watching years of strategic plans over a ten-year period fail to significantly alter the trajectory of their community care volume, he came to the sad conclusion that they would never win the primary care outmigration battle.


There is hope! …just not on the inpatient side (besides bringing more surgical specialties). Surprisingly, the best paths to reversing primary care outmigration is in the ambulatory Rural Health Clinic space where recent government-sponsored care coordination initiatives for Medicare patients have made it possible to rapidly increase volume and revenue.

Here are 5 proven strategies Rural Health Clinics can use to reverse the hospital primary care outmigration:

1. Recruit your zip code population (not just your EHR population) to Annual Wellness Visits (AWVs)

Using call center service recruitment programs (which have been used by just about every other industry for a decade), RHCs offer access to our elderly population for wellness exams. After the visit, the patient is referred to the local community RHC for continued primary care.

2. Introduce Chronic Care Management (CCM) services

Using dedicated Case Managers, CCM, a monthly 20-minute patient interaction can generate an additional 4 visits/year to your clinic based on change in patient conditions, while decreasing ED visits by 10%.

3. Introduce Behavioral Collaborative Care Management

Using dedicated therapist with psychiatrist backup, these programs are approved for up to 20% of your Medicare population. Indications for program use are patients with cognitive decline, on chronic medications including opiates, antidepressants, and antipsychotics, as well as patients with evidence of substance abuse. Besides approved behavioral health therapy visits locally, therapists refer these patients back into the clinic systems for additional medical and surgical care as appropriate.

4. Increase community awareness of hospital and clinic services

Using technology systems that communicate directly to patients’ phones and allowing patients to self-schedule, hospitals can communicate to not just their patients, but to their entire primary service areas of services and allow patients to self-schedule clinic appointments. Easing the complexity of getting appointments for care makes the hospital RHC have a better mousetrap for clinic access and services to compete against the larger health systems.

5. Recapture your outbound transfers with Transitional Care Management

Using defined team members, successful RHCs assigned case managers who track all patients transferred to other facilities. They communicate with the patient and family from the date of transfer to plan and then arrange follow up visits back to their own communities.

These programs, when integrated to a single platform and approach, can rapidly increase ambulatory volumes by 60-100% within a few months of implementation. For more information on these programs, contact us. Besides your patients and your hospital, what do you have to lose?


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. Contact us at to learn how RHS has helped other rural hospitals to increase their long-term financial viability.

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