The COVID-19 pandemic has brought rural healthcare systems to the brink. In 2020, at least 20 rural hospitals closed—a new annual record since 2005.
Even before the pandemic, rural healthcare systems have been fighting for their lives. A recent report from the U.S. Government Accountability Office (GAO) found that 101 rural hospitals closed from January 2013 through February 2020. The report found people in the closed hospitals’ service areas would have to travel substantially farther to access certain healthcare services—the median distance to access some of the more common healthcare services increased about 20 miles from 2012 to 2018.
In addition to putting patients at risk of losing access to healthcare, hospital closures strike at the heart of a community. Hospitals are major employers and communities lose jobs, businesses, tax revenue—and people. Doctors, nurses, pharmacists, and other staff employed by the hospital often have to leave the area. GAO found that the availability of healthcare providers in counties with rural hospital closures generally was lower and declined over time.
The crisis in rural healthcare has many causes and the solutions are far from simple. Luckily, our nation’s leaders are starting to take action through various legislative and regulatory approaches. For example, the American Rescue Plan Act of 2021 provides $8.5 billion to reimburse rural healthcare providers for healthcare-related expenses and lost revenues attributable to the COVID-19 pandemic.
Notably, a bipartisan group of Senators has introduced the Save Rural Hospitals Act of 2021, which would help curb the trend of hospital closures in rural communities by making sure hospitals are fairly reimbursed for their services by the federal government. The House has also introduced the Rural Hospital Support Act, bipartisan legislation that would extend and modernize critical federal programs that rural hospitals rely on to properly serve their communities. If passed, these acts would help these community lifelines keep their doors open as we continue to face the lasting repercussions of the pandemic.
Another important solution gaining momentum among policymakers: allowing advanced practice nurses such as Certified Registered Nurse Anesthetists (CRNAs) and other nonphysician providers to practice to the full scope of their education and expertise.
CRNAs are in the thick of responding to this crisis as the sole anesthesia providers in the vast majority of rural hospitals, enabling these facilities to offer surgical, obstetrical, trauma stabilization, interventional diagnostic, and pain management services. Numerous studies have demonstrated that CRNAs provide safe, cost-effectiveanesthesia care.
Importantly, President Biden’s proposed Fiscal Year 2022 budget calls for added funding for the U.S. Department of Health and Human Services (HHS) to protect rural healthcare access and expand the pipeline of rural providers like CRNAs, noting, “The discretionary request also funds efforts to increase the number of individuals from rural areas going to medical school or other training programs, and returning or staying in rural communities to provide care, with a focus on primary care physicians, nurses, nurse practitioners, nurse anesthetists, and other in-demand providers.”
Additionally, in March 2020, the Centers for Medicare & Medicaid Services (CMS) temporarily removed physician supervision of physician assistants and advanced practice nurses to increase the capacity of the U.S. healthcare delivery system during the COVID-19 Public Health Emergency. This allowed CRNAs to step forward as indispensable providers responding to this unprecedented crisis. The waiver was extended by 90 days in April 2021 and HHS has indicated it is likely to remain through the year.
We can help address the rural healthcare crisis by applying the lessons learned during this tragic, unprecedented year. We need to move forward using all of the resources available and make the commonsense measures taken during the pandemic permanent. As these underserved areas need all of the help and resources that CRNAs and other nonphysician providers can give, the barriers that were temporarily waived last year must stay down.
The COVID-19 pandemic has laid bare fundamental, systemic problems within the U.S. healthcare system that will not go away when the pandemic goes away. Clearly, the nation cannot continue down the same path and do what we have always done.
A new link has been added to the Nurse Licensure Compact. In February 2022, Vermont will become the 35th state to allow nurses from other states to practice and treat patients without re-licensure. State legislators are also seeking other ways to reduce Vermont’s nursing shortage, and other measures under consideration include nursing school loan forgiveness and allowing nursing students to perform more clinical duties.
Vermont nurses are not universally applauding the law’s passage. The Vermont Federation of Nurses and Health Professionals expressed concern that the Licensure Compact will increase the flow of nurses departing from Vermont to seek higher-paying positions in states with a lower cost of living. However, this is a universal issue in states with substantial rural areas, and states like Oregon and Montana have been setting the pace with retention programs offering NPs and other healthcare providers tax credits and insurance incentives as well as school loan repayment and forgiveness, and Vermont appears to be pursuing a similar game plan.
Vermont Secretary of State Jim Condos praised the new law, commenting that the Nurse Licensure Compact bill “will ensure that qualified nurses from other states in the compact do not have to jump through hoops to practice in Vermont. COVID-19 showed how important it is to be able to quickly and efficiently license those qualified to care for Vermont patients in times of need.”
Office of Professional Regulation Director Lauren Hibbert chimed in, saying, that the bill “ensures quality care for Vermonters while providing mobility to Vermont nurses and nurses across the nation who wish to practice in the Green Mountain State. Our mission at the Office of Professional Regulation is to ensure the public’s safety and protect Vermonters from professional misconduct while making sure that qualified professionals who want to practice in Vermont do not face burdensome barriers to licensure.”
Registered nurses have been in high demand in the United States for over a decade, and projections on the job outlook from 2019-2029 indicate this profession will grow 7% faster than other jobs. In 2019, nurses ranked third as the most in-demand job of any profession in the U.S.
This demand for nursing care reflects employers are not keeping pace in supplying enough nurses to care for our communities. There are several reasons for the shortage of nurses, one being a growing population. As our population flourishes, we need more practicing nurses on the frontlines to care for everyone.
Second, people live longer because there are better medical treatments and medication therapies to help people stay healthier longer. Further, the number of nursing programs positioned to accommodate non-traditional learners may also be adding to the shortage.
Nurses are highly respected and work in various settings such as hospitals, clinics, physicians’ offices, home healthcare services, nursing facilities, schools, and more.1 The nurse works collaboratively with physicians, pharmacists, and other healthcare professionals to provide comprehensive health care.
It should not come as a surprise that nurses have been deemed the most trusted profession year over year. Registered nurses (RNs) are fortunate to be at the center of the care model to care for the sick and promote health and wellness across the continuum.
With the ever-changing technology and advances in research, there are many opportunities for nurses to advance within the profession. From neonatal care, pediatrics into adulthood, and geriatrics, RNs receive the education to care for all ages throughout the lifespan. With experience, RNs can become specialized in an area of nursing such as cardiac care, emergency care, pediatric, or oncology care.
Opportunities exist to close the gap and reduce the growing shortage of RNs, especially in rural areas and the midwestern states. For those who have been thinking of a career in healthcare or a second career change, nursing may be the right fit for you.
RNs typically have enhanced benefits in the workforce that make it more attractive. These include flexible hours to meet family work-life balance, full-time and part-time work schedules, excellent health plans, 401k or other retirement investments, an annual median wage of $75,330, and job security from these high-demand jobs.
If you are interested in a highly respected nursing career, Elmhurst University, located west of Chicago, has a program designed for you. Elmhurst is academically strong and ranked by U.S. News & World Report as a leading Midwest University.
Accredited by the Commission Collegiate Nursing Education (CCNE), Elmhurst University is proud to provide a distance accelerated BSN (ABSN) nursing program. This elite degree is the first of its kind in Illinois. The robust course curriculum is structured to be completed in 16 months, a fast-track for full-time students, with all coursework happening entirely online. Students complete clinicals in their local community and have two campus visits built into the program.
Elmhurst University is dedicated to providing ABSN students with integrated support to foster success. From the moment you begin your application process through receiving your well-deserved diploma at graduation, advisors are assigned to help you navigate and stay on target in meeting degree goals and requirements.
According to the 2019 Centers for Disease Control and Prevention’s State Rankings for Health Outcomes, Kentucky has some of the highest obesity, diabetes, cancer, and heart disease rates in the United States. Many of the state’s rural counties are among the worst for health outcomes. At the same time, much of the state faces a shortage of registered nurses, with rural areas having the greatest need.
Beginning this fall, the Ag Nursing Scholars Program for Kentucky Health and Wellness will provide a way for students in majors in CAFE’s Department of Dietetics and Human Nutrition to seamlessly earn a second degree in nursing. Students will earn a Bachelor of Science degree in either dietetics or human nutrition from CAFE and then pursue an accelerated Bachelor of Science degree in nursing from the College of Nursing.
“This partnership is exciting, and we hope to succeed in supporting well-rounded student programs to create healthier communities,” said Nancy Cox, UK vice president of land-grant engagement and dean of the College of Agriculture, Food and Environment.
“The College of Nursing is thrilled to announce this new partnership with the College of Agriculture, Food and Environment, giving students an opportunity to train and develop a broad set and depth of skills that will make them uniquely qualified to excel in their future careers,” said Janie Heath, dean and Warwick Professor of Nursing in the College of Nursing. “This type of dual-degree opportunity is what gives our University of Kentucky students a competitive advantage over other graduates in the fields of health care, nutrition and education.”
During the program, students will complete a variety of experiential learning activities and undergraduate research. As part of the nursing program, they will also receive Certified Nursing Assistant training and more than 700 clinical hours of guided learning from faculty and clinicians specializing in six specialties.
Access to simulation training could be a game-changer for nurses and other healthcare workers in rural Iowa, where training and continuing education (CE) has long been an ordeal. A nurse in the Iowa heartland may have to drive hundreds of miles to learn new techniques at a distant city hospital. Fortunately, healthcare workers in the state’s more thinly populated areas will soon be able to hone their skills thanks to a new $8 million dollar grant through the University of Iowa College of Nursing.
The grant money is coming from the rural healthcare program at the Helmsley Charitable Trust, which has donated millions to underserved rural areas since 2009. The program covers eight states: South Dakota, North Dakota, Nebraska, Wyoming, Minnesota, Montana, Nevada, and now Iowa. Walter Panzirer, a trust representative, said their aim is to build a sustainable, long-term simulation program to support health care providers’ continuing education in these states: “We hope to improve quality outcomes because the more you can train on something, the better the outcomes will be.”
According to the Daily Iowan, the grant will help launch the Simulation in Motion (SIM) project in Iowa. The SIM project, founded seven years ago by a group of South Dakota healthcare providers, spearheads the development of simulation training programs in midwestern states to help rural HCPs keep their skills fresh and learn how to implement new techniques and treatments for unusual conditions. The U Iowa College of Nursing is using the funds to invest in three mobile training units designed to look like emergency departments and ambulances. The ED/ambulance units will be equipped with patient simulators, medical equipment, and educators to conduct the training. Inside the trucks, educators will train students and local HCPs on the simulators, which have human-like anatomies that can mimic a range of conditions and complications.
Jacinda Bunch, the co-director of SIM – Iowa, notes that “Some emergency situations are not seen very often, and it’s hard to keep up on those skills and remember everything you should do.” Bringing the simulations to these areas helps rural health care providers train closer to home so they do not have to engage in lengthy, expensive commutes to city hospitals to develop these skills. Bunch remarked that for rural HCPs months or even years can pass without encountering certain medical situations, and when such situations do arise, rusty or outdated skills can result in worse outcomes.
The opportunity to work with simulations is a boon for nurses and other practitioners in Iowa’s remote parts, says Cormac O’Sullivan, clinical associate professor of nursing and co-director of SIM – Iowa. “Health care providers really remember what to do when they do simulations. As the students and providers practice, they become more comfortable in the scenario and more open to learning and retaining it better.”
Mary Barnett is one of about a dozen seniors who got a covid-19 vaccine on a recent morning at Neighborhood Health, a clinic tucked in a sprawling public housing development on the south side of downtown Nashville, Tennessee.
“Is my time up, baby?” Barnett, 74, asked a nurse, after she’d waited 15 minutes to make sure she didn’t have an allergic reaction. Barnett, who uses a wheelchair, wasn’t in any particular rush. But her nephew was waiting outside, and he needed to get to work.
“Uber, I’m ready,” she joked, calling him on the phone. “Come on.”
Seniors of color like Barnett are lagging in covid vaccinations, and the Biden administration plans to redirect doses to community clinics as soon as next week to help make up for the emerging disparity. Tennessee is one of a few states allocating vaccines to the network of clinics known as FQHCs, or federally qualified health centers.
In most of the states reporting racial and ethnic data, a KHN analysis found that white residents are getting vaccinated at more than twice the rate of Black residents. The gap is even larger in Pennsylvania, New Jersey and Mississippi.
“Equity is our north star here,” Dr. Marcella Nunez-Smith said at a briefing Tuesday, announcing vaccine shipments to the federally funded clinics. “This effort that focuses on direct allocation to community health centers really is about connecting with those hard-to-reach populations across the country.”
Nunez-Smith, who leads the administration’s health equity task force, said federally funded clinics — at least one in every state — will divvy up a million doses to start with, enough for 500,000 patients to get both doses. Eventually, 250 sites will participate.
The administration said roughly two-thirds of those served by FQHCs live at or below the poverty line, and more than half are racial or ethnic minorities.
Seeking People Out
In Nashville, more than a third of eligible white residents have gotten their first shot, compared with a quarter of Hispanic residents and fewer than one-fifth of Black Nashvillians.
Unlike many local health departments, Neighborhood Health is not fending off crowds. They’re seeking people out. And it’s slow work compared with the mass vaccination campaigns by many public health workers and health systems.
Barnett lives in a public housing complex that gathered names of people interested in getting the vaccine. She was lucky to have her nephew’s help to get to her appointment; transportation is a challenge for many seniors. Some patients cancel at the last minute because a ride falls through. Often, the clinic offers to pick up patients.
Aside from logistical challenges, Barnett said, many of her neighbors are in no rush to get their dose anyway. “I tell them about taking it, they say, ‘Oh, no, I’m not going to take it.’ I say, ‘What’s the reasoning?’”
Usually, Barnett said, they don’t offer much of a reason. Her own motivation is a sister with kidney disease who died of covid in July.
“You either die with it or die without it,” her brother told her in support of getting the vaccine. “So if the shot helps, take the shot.”
Same Story, Next Chapter
People of color have made up an outsize share of the cases and deaths from covid nationwide. And, predictably, the same factors at play driving those trends are also complicating the vaccine rollout.
Rose Marie Becerra received an invitation to get the vaccine through Conexión Américas, a Tennessee immigrant advocacy nonprofit. A U.S. citizen originally from Colombia, she’s concerned about those without legal immigration status.
“The people who don’t have documents here are nervous about what could happen,” she said, adding they worry that providing personal information could result in immigration authorities tracking them down.
And unauthorized immigrants are among those at the highest risk of covid complications.
Even with 1,300 total community health centers around the country, Neighborhood Health CEO Brian Haile said his 11 clinics in the Nashville area can’t balance out a massive health system that tends to favor white patients with means.
Haile said everyone giving vaccines — from hospitals to health departments — must focus more on equity.
“We know what’s required in terms of the labor-intensive effort to focus on the populations and vaccinate the populations at the highest risk,” Haile said. “What we have to do as a community is say, ‘We’re all going to make this happen.’”
Republished courtesy of KHN (Kaiser Health News), a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.