COMMENTARY Can Adult Care Be Regionalized? An Approach Giving the Best Care While Supporting Community Catherine Clary, JD ;1 William Kanto, MD;2 Nikki King, MHSA;3 & Tim Putnam, DHA3

1 Institute of Public & Preventive Health, Augusta University, Augusta, Georgia 2 Medical College of Georgia, Augusta University, Augusta, Georgia 3 Margaret Mary Health, Batesville, IN

For further information, contact: Catherine Key words access to care, health disparities, hospitals, policy, utilization of Clary, JD, Institute of Public & Preventive Health, health services. Augusta University, Augusta, Georgia; e-mail: [email protected] doi: 10.1111/jrh.12391

Regionalization of is not a new approach, and patients appropriately transferred, insuring universal ac- it may be a critical tool for the survival of rural com- cess to these services and improved outcomes. munity hospitals. Perinatal care regionalization was de- Numerous services can be provided in their entirety veloped in the 1960s, given its advances in the care of by rural hospitals for the benefit of the community, and mothers and infants and development of neonatal inten- these services can be even more robust and broader in sive care units (NICU),1 after it became clear that the scope with a vibrant telehealth connection for consulta- neonatal mortality rate and the infant mortality rates tions and a strong continuing education program. Many were unacceptable. Perinatal regionalization is generally physicians in rural community hospitals are accepted as being a significant contributor to the de- concerned that they are practicing outside of their scope cline in neonatal mortality and improving other perinatal of service without subspecialty consultation; hence, the statistics. patient is often transferred.3 If the consult could be ob- Although the system has evolved to a degree, the tained via telemedicine, in many cases the patient could founding principles are still operational: a perinatal cen- be retained in the rural community with con- ter within a NICU would be responsible for providing tinuing support, if necessary.4 Rural hospitals can serve care not only to patients in its hospital, but in a region. as the entry point into a coordinated health care system Consultations from regional providers would be quickly for patients, providing patients with services that can be answered and assistance provided so that best options supported locally and initiating continuing care services for the patient would be determined. When requested to be provided in tertiary facilities. By partnering with an by a referring facility, the transfer would take place as academic medical center or other tertiary facility, rural quickly as possible. After services were rendered, mother hospitals may leverage the relationship to provide con- and/or baby would be returned to their home facility as tinuing education services to their providers. Patient care quickly as their condition would allow, so continuing care will be enhanced in this system and some of the problems could be directed by the provider following them post dis- inherent in a fragmented system will also be addressed. charge. Rural hospital closures are catastrophic to the fiscal Just as not all perinatal services could be provided in and physical health of small communities.2 Among other every community hospital, today there are specialized problems, the prompt availability of emergency services life-saving services (such as stroke, cardiovascular, and contributes to a community’s reduced morbidity and trauma) available that cannot be fully supported by ev- mortality; if the emergency services are connected to spe- ery rural hospital.2 However, in an organized system of cialized care and continuing treatment, the impact is even care, treatment can be initiated in the rural hospital and greater. Rural hospitals and associated clinics are often

The Journal of Rural Health 0 (2019) 1–3 c 2019 National Rural Health Association 1 Adult Care Regionalization Claryetal. the focal point for health care within the community. community hospital, there will be growing respect and Patients transferred to specialized services may not have trust among the providers, leading to improved pa- post-acute services readily available when returning to tient care and patient satisfaction. the community, and continuity of care may be compro- mised. If a patient is transferred to a tertiary facility, we Lack of clinical volume is a universal issue causing fi- believe every effort possible should be made to return nancial problems for rural hospitals. With sufficient clin- the patient to the community hospital for convalescent ical volume, a rural hospital can generally survive2 and care and post-discharge planning. It is easier to do this be a resource for community health as well as an eco- if the rural hospital has a swing bed program, where nomic support. The challenge, then, is to provide services rural hospitals may use a bed as either an acute care in the rural hospitals that provide sufficient volume, are bed or a skilled bed, but every avenue should be within the scope of practice of the system, and are finan- exhausted to make this happen. By returning the patient cially viable. It is also essential to convince the commu- to the community hospital, the patient’s family incurs nity to use these expanded services and to demonstrate less expense and travel time. Transferring the patient that the community hospital is part of a larger, compre- back to the community hospital demonstrates the tertiary hensive system. center’s confidence in the rural hospital and providers In this model of emulating perinatal regionalization in the community. As a result, clinical volume in the for adult care regionalization, we are making several as- community hospital increases, transferring allows the sumptions: community hospital to provide post-discharge services, and continuity of care is promoted by providers. Finally, 1. Systems and protocols can be developed between hos- the local hospital is the nexus for the continuing care for pitals and implemented, which will allow patients the patient; local providers are available to answer ques- who need specialized services to be transferred with- tions about medications, rehabilitation, and follow-up out impediment or delay, and these systems will also care, reducing the chance for error and confusion. support the initiation of diagnostic and/or therapeutic Regionalization frees up the tertiary hospital to use its care. facilities for care that cannot be provided in other set- 2. The capacity of rural hospitals to provide services tings and may thus contribute to a reduction in diversion to patients can be expanded through the use of times. A system of regionalization would be instrumental telemedicine. in maintaining rural hospitals, which is critical in caring 3. Transferred patients can and should be transferred for the rural population. Data on clinical outcomes for back to the rural community hospital after discharge common surgical procedures show no significant differ- forr the following reasons: ence in cost or outcomes between community hospitals Fewer errors in terms of post-discharge medicines, and tertiary facilities.7 rehabilitation, and follow-up appointments, since Some health systems are putting similar models in the local provider can provide support and answer place using traditional “hub and spoke,” particularly with questions as the primary care physician (PCP). By stroke and trauma. These models ensure patients’ access involving the PCP, there will be improvements in to tertiary care while working to maintain the rural base. communication with both the patients and fam- Although the bulk of care in these models will occur in ily, as well as an increase in adherence to post- ambulatory settings, those facilities are stronger if there 5 r discharge care plans. is support from a rural hospital and strengthened with Patients prefer to get as much of their care within telemedicine. their community as possible. Upon demonstration The survival of rural hospitals is an essential compo- that the rural hospital is part of a larger, integrated nent in providing health care to a rural community, and system, patients will be more likely to use the com- rural hospitals are integral to the economic development 6 r munity hospital as their gateway to care. and future growth of the community. With adult region- Rural community hospitals will continue to be an alization, patients receive required tertiary care, but the integral component to the delivery of health care in community hospital is supported through its use for re- their communities, enhance patient care, and im- habilitation and continued wellness. prove the health of the community in accordance with the triple aim of improving the patient experi- References ence, reducing cost, and increasing access. 4. With the increase in organized cooperation in pa- 1. Lester BM, Hawes K, Beau A, et al. Single-family tient care between the tertiary hospital and the rural room care and neurobehavioral and medical outcomes

2 The Journal of Rural Health 0 (2019) 1–3 c 2019 National Rural Health Association Clary et al. Adult Care Regionalization

in preterm infants. Pediatrics. 2014;134(4):754-760. 5. West C. Coordinating closings in primary care vis- http://pediatrics.aappublications.org/content/134/4/754. its: producing continuity of care. In: Heritage J, Accessed June 2019. Maynard DW, eds. Communication in Medical Care: 2. Wishner J, Solleveld P, Rudowitz R, Paradise J, Antonisse Interaction between Primary Care Physicians and Pa- L. A Look at Rural Hospital Closures and Implications for Access tients. Studies in Interactional Sociolinguistics. Cam- to Care: Three Case Studies. San Francisco, CA: The Kaiser bridge, UK: Cambridge University Press; 2006:379-415. Family Foundation; 2016. https://www.kff.org/report- https://doi.org/10.1017/CBO9780511607172.01 section/a-look-at-rural-hospital-closures-and-implications- 6. Salisbury C, Purdy S. Providing care for-access-to-care-three-case-studies-issue-br. Accessed closer to home. BMJ. 2007;335:838. July 31, 2019. https://doi.org/10.1136/bmj.39371.523171.80. Accessed 3. Daniel HB, Snyder Sulmasy LJ. Policy recommendations to July 31, 2019. guide the use of telemedicine in primary care settings: an 7. Ibrahim A, Hughes T, Thumma J, Dimick J. As- American college of physicians position paper. Ann Intern sociation of hospital critical access status with sur- Med. 2015;163(10):787-789. gical outcomes and expenditures among Medi- 4. Moffatt J, Eley D. The reported benefits of telehealth for care beneficiaries. JAMA. 2016;315(19):2095-2103. rural Australians. Aust Health Rev. 2010;34(3):276-281. https://doi.org/10.1001/jama.2016.5618

The Journal of Rural Health 0 (2019) 1–3 c 2019 National Rural Health Association 3