Covid-19’s Impact on Healthcare in Rural America

During the first few months of the COVID-19 pandemic, many of the images Americans saw were of hospital workers overrun on the frontlines in major metropolitan areas like New York, New Jersey, Los Angeles, and San Francisco. Even if not faced with the same volume of cases, hospitals in rural America have their own COVID-19 related challenges.

For example, the state of North Carolina does not see the same volume of COVID-19 cases, per capita, as other southern states like Florida or Georgia. Still, many hospitals in the state have suffered a series of debilitating financial blows. As one of the states that did not expand Medicaid coverage under the Affordable Care Act, North Carolina has a high number of uninsured who are also suffering other conditions, as well. And as fearful patients canceled routine appointments and hospitals postponed elective procedures to make critical resources available for possible COVID-19 surges, many North Carolina health systems have seen revenue sources evaporate. To stanch the flow and keep their hospitals open and available to serve all patients, the state’s hospital administrators have had to get creative.

SensisHealth’s Sharon Carothers recently interviewed Cynthia Charles, Vice President of Communications and Public Relations of the North Carolina Healthcare Association, to discuss the impact of COVID-19 on the healthcare industry in her state.  Charles spoke about how a willingness to adopt new approaches to communications helped her keep her hospitals supplied, resilient, and able to meet the needs of a diverse patient population.

Q: What are some of the biggest challenges you've faced in the last couple of months related to COVID-19?

A: I think challenge number one was understanding what we were dealing with, and what the plan was. 

As an advocacy organization, we have a lot of interaction with the federal and state governments, hospitals, and health systems that were asked to put elective procedures on pause at one point, which is a major source of income for them. That immediately put them into a very difficult financial situation, not only because their main revenue source was put on pause, but also because they were trying to procure medical supplies and PPE that were so much more expensive than they normally were. And the suppliers didn't have inventories. They were forced to look overseas, to find suppliers, to even procure items. And many of these companies were not known to them. Imagine you're a smaller rural hospital in North Carolina that needed to procure items--how are you going to do that? Our association developed a very innovative, progressive, and collaborative way for us to do group purchasing and vet suppliers and use a digital platform to make it easier for everybody.

So those are just a couple of challenges. I think it’s important to stay in touch with the state and federal governments to try to understand their plans. What's the plan for testing and tracing? What's the plan for stay-at-home orders or reopening the economy?

Q: Could you talk a little bit more about some of the challenges of having micro-systems that are unique in dealing with COVID-19? 

A: Sometimes rural communities are at a disadvantage.  North Carolina has never expanded Medicaid. Many of our rural hospitals have patients who are uninsured. And they are dealing with other health challenges like health disparity, food insecurity, language barriers. We have to educate and protect the health of our more vulnerable populations.

Hospitals have needed to work very closely in the counties with the public, with the county public health department and infrastructure, with their local business community. So, we all work together to keep everybody safe and informed about their options and where they can go for testing in urban areas.

We had concerns around population density; we didn't have enough testing supplies. We feel like we had a complete picture of the rate of spread and how to keep people safe. But we worked with the University of North Carolina and Wake Forest Baptist Medical Center who had developed and deployed their own tests, or already had outreach programs in place like mobile clinics, video visits, and telehealth programs.

We would also have weekly information-sharing calls with healthcare associations and our member hospitals and health systems, and medical societies representing the physicians, nurse associations, and hospice and palliative care skilled nursing facilities. It was really looking at a broad, inclusive cross-section of the healthcare industry, sharing information on a regular weekly basis on these conference calls.

Q: What are some of the long-term implications of your operations?

A:  Actually, we recently had a conference call with our CEOs and members called the COVID Forward call to assess what we need to do to be effective going forward. One thing that came up was the importance of keeping open lines of communication with the business community, since they are employers. Hospitals and businesses are suffering, and we all want to keep our employees and communities safe. We were mostly very aligned but, at times, had some debate, and healthy discussion, about reopening strategies and timing.

Another thing that we discussed was the importance of hospitals being very open and transparent with the community about what their needs are and why they're doing what they're doing.  There have been, for example, a lot of questions about visitor policies and people trying to understand why they can’t be with their loved ones in the hospital. But again, there's a lot for us to learn and we're trying to keep everybody safe.

Q: What's been working in terms of communicating to patients or to the community at large amidst all the constant changes?

A: I certainly think for health systems and hospitals that already had electronic newsletters, or patient- facing communication through MyChart (an EHR and patient portal), have really helped keep the community updated. I've seen health systems and hospitals do Facebook Live briefings and take questions. I've seen them do podcasts or radio shows or virtual town hall meetings using zoom technology; it's been extraordinary. 

Q: And while we're on the topic of technology, I'd love to hear more about the use of tech in your own work or elsewhere.

A: I think two of our greatest success stories have been my team at the North Carolina Healthcare Association, working with a Raleigh television station to produce a series of public service announcements. They were initially about the importance of staying at home, and then later about how you shouldn’t hesitate to call 911 if you’re having an emergency.

Then we did some PSAs about the importance of wearing a face covering, to be thoughtful and care for your family and your neighbors by wearing your mask. They were able to produce it at no cost to us. And we shared those PSAs with the North Carolina Association of Broadcasters so they could make them available to television stations across the state. It was a way for us to reach all people, even in rural areas.

Q: What areas of healthcare have you been focusing on during this time? How are these priorities shaping the future?

A: I think one of the most pressing priorities has been advocacy with the federal government so that hospitals were included in the CARES Act and that our state legislators understand why our hospitals need adequate funds.  I think that has been probably the top priority of our advocacy work so far. There have also been all types of waivers that can be put in place in order to allow hospitals to move quickly to do what they need to do. We have not only advocated for those waivers but keep a running database of them. That way, we can consider if any of them should be made permanent.

Q: Is there anything you're seeing around the application of COVID-19 and challenges that are different from regular care or vaccinations management of chronic conditions?

A: Absolutely. I've been very impressed with some of our hospital and physician group members. They’ve taken time to just look at their patient populations, where people live and what their health status was before COVID-19. They're reaching out to patients, especially if they're concerned that a patient is elderly or at high risk, to make sure that they're okay with their medications and they understand what their next visit is going to be, whether it's a virtual visit or in person. I think despite the fact that we're still going through a very serious and intense pandemic, we have primary care practices that are reaching out and doing the right thing for patient care.

Q: Have you seen any increases of telehealth especially in the rural community?

A: We've definitely seen an increase. Some health systems and hospitals were already using telehealth extensively, but we certainly have seen an expansion and patients have given us positive feedback.  It’s something we'd certainly expect will continue.

We also created the “fill the gap response fund” to fulfill certain needs for proactive care or reimbursement that were not going to happen through the federal and state level and things like the CARES Act. We wanted to make sure we were being proactive in looking for and addressing underserved populations across the state, many of whom were minority populations or in rural communities. Charitable organizations were lead donors in the effort but we also had a lot of individual donors. And so far, we've raised $5 million. This week, we're distributing a portion of $1.6 million in grants to 19 organizations. And most of these organizations are reaching out to support groups with COVID-19-related needs that serve are black populations in rural communities. These funds can be used for services like more virtual visits, more mobile clinic use, but also, education, and Spanish language education.

The last thing I would say is that I think we're still going to be dealing with COVID-19 for another 18 months at least, which is why I think it's so important to capture learnings and insights now and communicate successful practices because I think we're going to see a lot more of it in the fall and winter.