The WAMI Rural Hospital Project. Part 3: Building health care leadership in rural communities.

The WAMI Rural Hospital Project (RHP) intervention combined aspects of community development, strategic planning and organizational development to address the leadership issues in six Northwest rural hospitals. Hospitals and physicians, other community health care providers and local townspeople were involved in this intervention, which was accomplished in three phases. In the first phase, extensive information about organizational effectiveness was collected at each site. Phase two consisted of 30 hours of education for the physician, board, and hospital administrator community representatives covering management, hospital board governance, and scope of service planning. In the third phase, each community worked with a facilitator to complete a strategic plan and to resolve conflicts addressed in the management analyses. The results of the evaluation demonstrated that the greatest change noted among RHP hospitals was improvement in the effectiveness of their governing boards. All boards adopted some or all of the project's model governance plan and had successfully completed considerable portions of their strategic plans by 1989. Teamwork among the management triad (hospital, board, and medical staff) was also substantially improved. Other improvements included the development of marketing plans for the three hospitals that did not initially have them and more effective use of outside consultants. The project had less impact on improving the functioning of the medical chief of staff, although this was not a primary target of the intervention. There was also relatively less community interest in joining regional health care associations. The authors conclude that an intervention program tailored to address specific community needs and clearly identified leadership deficiencies can have a positive effect on rural health care systems.     

The Use of Community Surveys for Health Planning: The Experience of 56 Northwest Rural Communities

A rural health services development program of the University of Washington School of Medicine has worked for 15 years with communities throughout the five-state region of Alaska, Idaho, Montana, Washington and Wyoming to strengthen their health systems. In the course of that work, 56 communities were surveyed about their utilization and opinions of local health systems. This database allows the following generalizations to be made about rural Northwest communities: (1) People think highly of their local hospitals, physicians and other key components of the acute medical care system and want their hospitals to remain open. Older respondents are more satisfied than younger respondents; (2) the typical hospital market share is 36 percent, the typical physician market share is 50 percent (3) satisfaction with discrete, well-funded services such as pharmacy, ambulance and dentistry is quite high, whereas satisfaction with mental health and substance abuse treatment is significantly lower; (4) the most commonly cited serious problems in surveyed communities were "too few physicians or- services" and "care is too expensive"; and (5) there is great variation between communities in both satisfaction and utilization.     

Rural Health Research Community Perceptions of the Effects of Rural Hospital Closure on Access to Care

The purpose of this case study was to ascertain the perceptions of health professionals who were located in six rural communities where hospital closure occurred, regarding the impact of closure on community residents. These health professionals were asked to respond to questions about effects of hospital closures on the availability of medical services such as emergency care, physician services, hospital services and nursing home care. To control for trends in medical services utilization that were unrelated to hospital closure, the study design included comparison areas where similar hospitals remained open. A standardized questionnaire was administered to three health professionals in each of the areas that experienced a hospital closure and also in the matched comparison areas. Interviews of the health professionals in closure areas provide evidence suggestive of some perceived negative effects of hospital closure on these communities. These negative effects include difficulty recruiting and retaining physicians, concern of residents about the loss of their local emergency room, and increased travel times to receive hospital services. The perceived effects of closure appeared to be mediated by the distance required for travel to the nearest hospital. Respondents perceived increased travel times to most significantly affect vulnerable populations, such as the elderly, the disabled and the economically disadvantaged. Respondents in the majority of comparison areas also reported access barriers for vulnerable populations. These barriers primarily center on problems of obtaining transportation and enduring the rigors of travel. Improvements in the availability of transportation to medical care may offer some stabilization to communities where hospitals closed; however, it also is the case that transportation improvements are needed to increase access to care in rural communities where hospitals remained open.     

Hospital service scope expansion and market share improvement: a dynamic modeling and multivariate approach.

In a national trend, large, acute-care hospitals located in urban areas of the nation were continuously broadening their service scope, adding services at the rate of one each year, from 1982 to 1987. This study proposes that the underlying rationale of hospital service-scope expansion is status-gap minimization. This perspective was quantitatively interpreted and tested by a dynamic modeling analysis. Findings support status-gap minimization as the rationale for service-scope expansion. Using multivariate regression and dynamic modeling analysis, the study demonstrates that the cross-sectional relationship between two steady states--the relationship between service scope and market share--is positive and statistically significant. However, the market share change is not related to hospital service scope. The interpretation offered is that hospitals expand the scope of services looking not so much to increase their market share benefit in the short run as to raise their organizational status. In the long run, higher organizational status such as broader service scope then benefits market share.     

The WAMI Rural Hospital Project. Part 6: Overview and conclusions.

The Rural Hospital Project (RHP) appeared to make a meaningful difference in the six Northwest rural communities that participated in this integrated community development and strategic planning effort. Although the methodological approach used in the evaluation precludes us from attributing observed changes in outcomes solely to the project interventions themselves, several elements of the process appear to be useful in stabilizing or expanding local health care systems. These include: (1) the involvement of outside organizations in fostering community change, (2) a high degree of community commitment and investment in all stages of the process, (3) comprehensive identification of problems in the health care system by outside consultants, (4) the use of periodic meetings of communities confronting similar issues, (5) identification and development of local leadership, (6) enhancing teamwork among local health care providers, and (7) the development of conflict-resolution mechanisms within health care organizations. Future attempts to use this strategy to strengthen rural health care systems can be enhanced by broadening the range of participation in health services planning, enlisting involvement of medical staff throughout the strategic planning cycle, addressing the issue of physician recruitment, and clarifying responsibility for implementation of community plans. Rural communities will predictably need to identify and resolve a set of core issues. To the extent that external organizations such as medical schools can strengthen the ability of rural health professionals and community leaders to identify and address these issues, the quality and viability of rural health care systems will be enhanced.     

The Proximity of Predominantly African American and Hispanic Rural Communities to Physicians and Hospital Services

This study assesses how local physician concentrations and distances to hospitals differ for rural communities of varying African American and Hispanic compositions. The authors used data at the town-area level (i.e., towns and their immediately surrounding minor civil divisions and census civil divisions) for 9 Southern and 6 Western states, primarily for 1990. Data were from the US. Census, American Medical Association, and American Hospital Association. Analyses compared nonmetropolitan town-areas with low, medium, and high proportions of African Americans and Hispanics on their local physician-to-population ratios and distances to nearest hospitals offering each of four levels of services. The authors found that Western town-areas having over 50% Hispanic populations had lower physician densities than other Western town-areas that were predominantly non-Hispanic White (24.2 vs. 31.2 physicians per 100,000 population). In Southern town-areas, physician densities did not covary meaningfully with the proportion of African Americans. Distances to the nearest hospitals offering basic, intermediate, and tertiary subspecialty services were generally 25% to 35% farther for Southern town-areas composed of over 60% African Americans and for Western town-areas composed of over 50% Hispanics, compared to communities with more than 80% non-Hispanic White populations within each region. These relationships were not attributable to confounding by extraneous state factors, but in some cases were explained by community sociodemographic differences other than race. Thus, the authors learned that rural communities with populations that are predominantly Hispanic, but not those predominantly African American, face longer travel distances to physicians, and both groups face longer distances to some types of hospital services than rural communities with few minorities.     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

Defining rural hospital markets.

OBJECTIVE. The purpose of this study is to examine the geographic scope of rural hospital markets. DATA SOURCES. The study uses 1988 Medicare patient discharge records (MedPAR) and hospital financial information (HCRIS) for all rural hospitals participating in the Medicare Program. STUDY DESIGN. Hospital-specific market areas are compared to county-based market areas using a series of geographic and socioeconomic-demographic dimensions as well as indicators of market competitiveness. The potential impact of alternative market configurations on health services research is explored by estimating a model of rural hospital closure. DATA COLLECTION/EXTRACTION METHODS. Hospital-specific market areas were defined using the zip code of patient origin. Zip code-level data were subsequently aggregated to the market level. FINDINGS. Using the county as the hospital market area results not only in the inclusion of areas from which the hospital does not draw patients but also in the exclusion of areas from which it does draw patients. The empirical estimation of a model of rural hospital closure shows that the definition of a hospital market area does not jeopardize the ability to identify major risk factors for closure. CONCLUSIONS. Market area definition may be key to identifying and monitoring populations at risk from rural hospital decisions to downsize or close their facilities. Further research into the market areas of rural hospitals that have closed would help to develop alternative, and perhaps more relevant, definitions of the population at risk.     

The nature and extent of hospital competition in a government-funded health system.

A national study of Canadian hospitals assessed the perceived level and types of competition and the strategies pursued by these hospitals. Questionnaire data were obtained from chief executive officers in 715 hospitals, yielding a national response rate of 68%. Respondents indicated the perceived level of competition in the environment, the content of competition, and stated hospital strategies. Additional data were obtained on market share and hospital type. Close to half of the respondents indicated little or no competition in their environment, while 30% indicated substantial levels of competition. This represents a significant deviation from conventional wisdom about the Canadian health services environment. Respondents in hospitals with more than 75% of the market share were less likely to perceive competition than those with a smaller market share. CEOs in teaching hospitals and in hospitals located in larger communities reported higher levels of competition. Hospitals competed mostly for capital, programs, and staff; about a third of hospitals competed for patients and no differences were found by type of institution. Those hospitals in more competitive environments were more likely to indicate the use of diversification and horizontal integration as organizational strategies.     

Market Shares for Rural Inpatient Surgical Services: Where Does the Buck Stop?

Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals' surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals. In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. "Total hospital expenses" from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense. For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)     

Telemedicine and isolated communities: a UK perspective

There are still considerable inequalities in the provision of primary care in the UK in relation to need. Recruitment and retention of general practitioners (GPs) is a problem, although this is worse in inner-city than in rural areas. The main problem in rural areas of the UK is the accessibility of health services. GP consultation rates, hospital outpatient attendance rates and inpatient admissions all decline with distance both to the doctors' surgeries and to hospitals. There is evidence that health services can be successfully and effectively delivered to isolated communities by telemedicine, but almost all of it relates to work done outside the UK. The experience has been generally good and should certainly be taken into account when planning future physician requirements and distribution.     

Establishing a rural hospital cooperative: a case study.

Rural hospitals have traditionally been the providers of health services in rural areas. In recent years, however, rural hospitals have come under increasing economic and regulatory stress. Rural hospital cooperatives represent a new level of shared management that addresses mutual problems using a horizontal organizational model. In 1987, the Western New York Rural Health Care Cooperative was established by building on fragments of associations that had existed previously. Triggered by an opportunity for grant funding, a major regional cooperative evolved which has demonstrated effective responses to a variety of problems inherent in providing rural health care. Particularly successful programs have such features as a quality assurance plan that uses cooperative-wide peer review, nursing and allied health education, physician recruitment, and the active involvement of a university medical school. This paper is a case study of the development and success of the Western New York Rural Health Care Cooperative.     

Implementing swing-bed services in small rural hospitals.

Since 1983, twenty-six small rural hospitals in five states have been developing models of the "swing-bed" concept as part of a coordinated national demonstration project. Based on the experiences of these hospitals, swing-bed programs use excess hospital capacity to provide short-term, post-acute care in rural communities where there are nursing home shortages, and, thus, help avoid the need for new nursing home construction. The availability of swing-bed services in rural hospitals has allowed the elderly patient to receive a full-range of long-term care services within the community to avoid transfer to a nursing home outside the community. Introduction of services also has improved patient care for all hospitalized elderly. Finally, the revenue from the swing-bed services has helped to stabilize small, rural hospitals faced with declining utilization. The demonstration has provided evidence that the swing-bed program has the potential to deliver a needed service to the rural elderly while contributing to the preservation of the small, rural hospital as a valuable community resource.     

Impact of rural hospital closures in Saskatchewan, Canada

Canada's health care system has undergone major changes since 1990. In Saskatchewan, 52 small rural hospitals funded for less than eight beds stopped receiving funding for acute care services in 1993. Most were subsequently converted to primary health care centers. Since then, concerns have been raised about the impact of the changes on rural residents' access to care, their health status, and the viability of rural communities. To assess the impact of hospital closures on the affected communities, we conducted a multi-faceted, province-wide study. We looked at hospital use patterns, health status, rural residents' perceptions of the impact of these hospital closures, and how communities responded to the changes. We found the hospital closures did not adversely affect rural residents' health status or their access to inpatient hospital services. Despite widespread fears that health status would decline, residents in these communities reported that hospital closures did not adversely affect their own health. Although some communities continue to struggle with changes to health care delivery, others appear to have adapted as a result of strong community leadership, the development of widely accepted alternative services, and local support for creating innovative solutions. Good rural health care does not depend on the presence of a very small hospital that cannot, in today's environment, provide genuinely acute care. It requires creative approaches to the provision of primary care, good emergency services, and good communication with the public on the intent and outcomes of change.     

The health service needs of small rural communities

ABSTRACT: In recent years econometric models used in health service planning have tended to encourage the downgrading or closure of small rural hospitals with the effect of reducing access to services and transferring costs from health authorities to consumers. These changes have occurred despite mounting evidence that people in rural communities have specific health service needs which require special attention. This study aimed to identify the perceptions of community members, health professionals and administrators regarding the health service needs in their small rural communities as a basis for developing a more comprehensive model of rural health service planning. Focus groups were held in three selected towns in Gippsland, exploring participants' perceptions of the meaning of health, health service needs, impact of health services, and the best set-up for health services. Consistent with previous research, key findings include: a broad conceptualisation of health; the perceived overwhelming importance of doctors, hospitals and chemists; the economic and social importance of a rural hospital; and a preference for all health services being provided under the one roof, funding and program flexibility, and local involvement in health service planning and implementation.     

Our Community Hospital: The Evolution of a Rural Primary Care Hospital

In the next few years, Our Community Hospital, located in the small town of Scotland Neck, NC, will undergo a conversion through which it may serve as an appropriate model for similar small hospitals in distressed rural communities. With technical and grant assistance from the Office of Rural Health and Resource Development of the North Carolina Department of Human Resources, the hospital has begun to phase out almost all acute care services and will expand and strengthen its focus on primary care, emergency medical services, and services for elderly persons. This paper addresses four issues of greatest concern to hospital administrators, rural health professionals, academics, and rural residents interested in hospital conversions: (1) community involvement during the planning process; (2) the evolution of the program's structure; (3) financing for the project; and (4) the development of cooperation between state and federal governments, foundations, and private groups. This case study describes one possible course in addressing an acute health care problem facing rural America--the viability of rural hospitals.