Health Workforce Implications For The Rural Emergency Hospital Model

Hospital care has become increasingly difficult to access in rural areas. Since 2005, approximately 183 rural hospitals have closed in the United States. Many hospitals have shuttered their maternity wards, reduced surgical offerings, and shifted to providing more outpatient services. In response to this decline in services and the financial distress of rural hospitals, Congress created the Rural Emergency Hospital (REH) designation via the Consolidated Appropriations Act of 2021. The REH designation is the first new rural provider type since the critical access hospital (CAH) was established in 1997. The REH designation allows small rural hospitals with fewer than 50 beds to convert to institutions that do not provide inpatient care but offer 24-hour emergency services.

On June 30, 2022, the Centers for Medicare and Medicaid Services (CMS) released the proposed conditions of participation (CoPs) for REHs. These conditions outline which hospitals are eligible to convert to an REH and what services they are obligated to provide. Under the proposed rule, REHs would have to maintain an annual per-patient average of 24 hours or fewer, provide 24-hour emergency services, and maintain a transfer agreement with a level I or level II trauma center. Additionally, CMS is considering permitting REHs to provide low-risk childbirth-related labor and delivery services accompanied by outpatient surgical services if surgical labor and delivery intervention is necessary.

Rural hospitals that choose to convert to REHs will have to eliminate their acute inpatient services but must maintain a fully staffed emergency department along with laboratory, radiology, and pharmacy services similar to those required in CAHs today. These requirements present a range of workforce challenges for hospitals already facing significant financial distress and located in areas with a limited pool of health care providers. To successfully meet the needs of their communities for emergency and other health care services, REHs will need to be agile in addressing these workforce challenges.

Flexible Staffing

Rural hospitals have long depended on flexible staffing models that rely on a diverse set of providers to meet the needs of the communities they serve. Since 2005, CMS has permitted non-physician practitioners, including physician assistants, nurse practitioners, and clinical nurse specialists, to be the designated providers on-call for emergency services at CAHs. During the COVID-19 public health emergency, CMS waived the requirement that a doctor be physically present at the CAH to provide medical direction. CMS is requesting comments on whether to require a physician or non-physician practitioner to be on site at an REH at all times.

Given the shortage of health care providers in many rural communities, REHs will need to draw upon health care talent from a range of health care employers. Many REHs will likely be affiliated with rural health clinics (RHCs), leveraging these relationships to meet staffing needs. To meet the demand for nursing staff, REHs can collaborate with physician practices and long-term care facilities in their community. These staffing arrangements, less common in urban areas, can help rural communities address provider shortages while improving continuity of care as patients may see the same provider for primary care and emergency services.

Behavioral Health Workforce

REHs, like other rural hospitals, will play a central role in providing behavioral health services in their communities. Patients often obtain these services via primary and emergency care providers due to the stigma associated with accessing behavioral health care in rural areas. While REHs are not allowed to provide acute inpatient psychiatric care, they will be able to provide outpatient care and serve as an originating site for telehealth visits.

REHs can employ clinical psychologists, licensed clinical social workers, and other behavioral health providers to deliver integrated medical and behavioral health care at one location. Recently proposed changes to the Medicare Physician Fee Schedule could provide REHs with greater flexibility, allowing clinical psychologists and licensed clinical social workers to serve as the focal point for behavioral health care delivery. CMS is also considering changes to the physician supervision requirements for licensed professional counselors and licensed marriage and family therapists, making it easier for REHs to employ these providers to deliver behavioral health care.

Colocation And The Importance Of Team-Based Care

With the focus on outpatient care and elimination of the need for inpatient space, many rural hospitals converting to REHs will need physical renovation. While renovations do result in upfront financial costs, they present an opportunity to create physical space for REHs to colocate with a range of health and social care providers, including primary care practices, specialists, and other health and human services organizations. Colocation can help by spreading the cost of facility upkeep and improve care coordination in the community by increasing opportunities for team-based care.

Team-based care models based in rural hospitals have proven to be successful at improving patient outcomes. Having a wide range of health and social care providers physically present at one facility such as an REH could allow for the natural formation of interdisciplinary teams focused on improving patients’ health. Furthermore, this type of workforce transformation addresses the business need for rural hospitals to better align with primary care providers as revenue streams shift toward payment models focused on population health.

Workforce Recruitment And Retention

Hospitals cannot stay open without their staff. As rural hospitals consider converting to REHs, they must consider how to recruit and retain their workforce. Recruiting health professionals for rural hospitals remains challenging given that these facilities often have lower patient volumes and wages compared to urban hospitals. REHs can draw upon local health professions’ training programs and consider starting their own programs to recruit staff and expand available services. REHs can serve as rotation sites for health professions students, which can help attract future health care talent. In addition, REHs could consider starting or participating in physician and nurse residency programs, a proven recruitment tool for rural health care providers.

To retain the existing workforce, REHs should focus on deploying their staff in a way that keeps them happy and patients well. Rural providers often cite their satisfaction with the strong provider-patient relationships in their communities where they know their patients personally. Rural medicine often allows providers to have a broader scope of practice than practicing in an urban community. REHs should play to these strengths, empowering their staff to design initiatives that improve their experience at work while providing whole-person care to patients. Health care workers who feel valued and whose employer cares about their well-being are far more likely to stay.

Looking Forward

Conversion to an REH will be financially costly, and it remains unclear whether the proposed monthly facility payment combined with reimbursement at 105 percent of Medicare will be enough to support both the startup costs and long-term sustainability of REHs. One analysis found that only 68 rural hospitals might convert to an REH out of the nearly 1,700 that will be eligible.

Despite the financial challenges, conversion of a rural hospital to an REH creates an opportunity for rural communities to restructure and retool their health workforce to deliver whole-person care. Rural hospitals have proven effective at providing high-quality emergency care for patients. They can build on their record of achievement by leveraging their workforce to provide expanded primary and behavioral health services to the community.

Author’s Note

Rains’ work is supported by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS) under cooperative agreement No. UK6RH32513. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by the HRSA, HHS, or the US government. The author is completing a heath policy fellowship in the US House of Representatives.

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