February 2019

Vol. 46   No. 2

 Cover Story



Rural Providers Take Center Stage Amid Population Shiftshttps://www.providermagazine.com/Issues/2019/February/Pages/Rural-Providers-Take-Center-Stage-Amid-Population-Shifts.aspxRural Providers Take Center Stage Amid Population Shifts<div>​​</div> <div> </div> <div> </div> <div> </div> <div> Living in rural America these days is akin to swimming against the tide. As the population of the country steadily shifts to urban areas, both to cities and an ever-expanding sprawl of suburbia, those who remain in small towns often have to adjust to living amongst a shrinking number of people and scarcity of community services, even as they enjoy the attributes of a rural life.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>On a wider scale, the industries that make up the economic life of these smaller-sized locales have taken on even more important roles as mainstay employers, which could include schools, hospitals, and long term and post-acute care (LT/PAC) providers.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>And, because of this demographic transformation in the countryside, rural skilled nursing facilities (SNFs) and assisted living communities often are not only a leading employer, but also a focal point of civic life. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> The Same Pressures</h2> <div> </div> <div> </div> <div> </div> <div>Although urban and rural providers face many of the same pressures, such as finding qualified workers, maintaining occupancy levels, and building reliable relationships with hospitals and physician networks, the intensity of the challenges is much more acute in the small towns that dot the landscape outside the megalopolises now called home by a growing majority of people.</div> <div> </div> <div> </div> <div> </div> <div>​</div> <div> </div> <div>For example, the most recent skilled nursing housing data from the National Investment Center for Seniors Housing & Care shows the differences in rural versus urban occupancy, with the occupancy levels in the third quarter of 2018 at 80.5 percent for rural facilities and some 300 basis points higher at 83.4 percent for urban SNFs.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Calling on their sense of duty and general optimism, rural providers tell Provider that they accept the challenges and responsibility of being an economic engine for their communities, and also in being leaders in preserving a small town culture where knowing the neighbor and pitching in for the good of all is not old-fashioned, but a way of life.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">States Getting Aggressive</h2> <div> </div> <p class="ms-rteElement-P">A leader in the LT/PAC profession is Heath Boddy, president of the Nebraska Health Care Association, the state affiliate of the American Health Care Association. He tells <em>Provider</em> that while providers in rural settings are not giving up​ on their mission to provide high-quality care and comfort to residents, it has becoming increasingly more difficult in the past five to 10 years. There are data that prove those challenges, and several facilities across the state have closed.</p> <div> </div> <div> </div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/HeathBoddy.jpg" class="ms-rtePosition-1" alt="Heath Boddy" style="margin:5px 15px;" />Nebraska has experienced a significant trend of migration from rural to urban settings. Rural areas also have a different payer mix.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Now, fast forward to having fewer people in the community, fewer people with the ability to pay, and add it to Nebraska’s—at best—poor reimbursement.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>To combat these challenges, Nebraska’s providers have been getting creative. For example, seeking out international nurses to help meet staffing shortages has been growing in popularity in Nebraska.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>And the association is working on the reimbursement front, advocating to policymakers for improved funding and changes to methodology that would use quality components as a way to bolster Medicaid dollars. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“We are trying to build our relationships to make them stronger than ever with legislators and decision makers. Again, none of that is a guaranteed dividend, it’s just trying to shape what we can in this space,” Boddy says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Painting a Picture of <span>R​ural Life</span></h2> <div> </div> <div> </div> <div> </div> <div>Against that backdrop, among the most active rural provider groups is the not-for-profit Evangelical Lutheran Good Samaritan Society, which has a strong presence in the smaller population centers in states like Iowa and Nebraska and all around the Upper Midwest and Great Plains. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Three administrators from Good Samaritan discussed their unique businesses, making clear it is not easy to depict a provider’s life in modern rural America with a broad brush. While each community sees different aspects of the same challenges, there are basic questions that separate them, namely: Is the potential client base losing or gaining in size, can the community attract enough workers, what are the financial resources of community members, and is the hospital and physician network close enough and of a high enough caliber?</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Dianna Epp, administrator of a Good Samaritan skilled nursing, assisted living, and child daycare center in Syracuse, Neb., says staffing is always tough where she is since there are two competitive nearby markets in Omaha and Lincoln, Neb., siphoning off potential workers. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“We are 30 miles from Omaha and 30 miles from Lincoln, so we continually have to compete with some larger communities for staff,” she says. “We rely a lot on community members in Syracuse; 53 percent live in town, and 47 percent live within 30 miles.”</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>As is seen across the nation in all sizes of care settings, this shortage of available labor has forced many providers to tap agencies to fill openings. Epp says “fortunately” her community has not had to use agency staffing, calling it costly and inconsistent when compared with having homegrown talent.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Business Opport​unities Vary </h2> <div> </div> <div> </div> <div> </div> <div>Stacy Neubauer, an administrator for Good Samaritan’s Alma, Neb., facility, cites other challenges in making her community work, namely the competition from nearby SNFs and assisted living operators. </div> <div> </div> <div>Unlike many small town providers, she is not the only game in town when caring for elders and people with disabilities.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/StacyNeubauer.jpg" class="ms-rtePosition-1" alt="Stacy Neubauer" style="margin:5px 15px;" />“Census is a challenge for us since we have nursing home competitors within a 30-mile radius in either direction you go. There is a lot of competition,” she says. And, staffing a facility under such conditions is all that much harder.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“It has been a struggle to just get people. We don’t always find people who have the education for the job, like for CNAs [certified nurse assistants] and medical aides. The closest place to take classes [to become a CNA, for example] is 30 miles away and expensive and time-consuming,” Neubauer says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Her facility has 53 beds for skilled care, but budgets for 36 and has trouble keeping it at that level. In addition, there are 12 assisted living apartments in the complex.</div> <div>​​​​​​​​<br></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Local Resources Pl​ay <span>a Huge Role</span></h2> <div> </div> <div> </div> <div> </div> <div>John Kern, administrator for Good Samaritan’s Algona, Iowa, community takes a longer view of the rural provider life, having logged 38 years in the business, most of those with the company. His facility celebrated its 60th anniversary in 2018, marking decades of progress from a small SNF that opened in 1958 to one that today has 90 skilled beds, 16 apartments for assisted living residents, and 28 beds for independent senior living.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/JohnKern.jpg" alt="John Kern" class="ms-rtePosition-1" style="margin:5px 15px;" />Business has changed over time, and of late has featured the aforementioned problem of not being able to find workers, which is not surprising given the low unemployment rate in his county and the state, Kern says. In addition to using some agency help, existing staff have taken on the burden of working overtime to make sure residents get the quality care they deserve, he adds.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Census levels are mostly stable in the assisted living and seniors housing side, but for skilled nursing there are fairly wide fluctuations. A saving grace is that Algona is the largest community in the county and is the county seat, which means it is home to the county government and law enforcement, as well as the county-owned hospital.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“We have a small critical access hospital with 25 beds,” Kern says. “But, we do need to drive 50 to 60 miles away for specialty care.”</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Getting these specialists to make a trip to Algona, or drive close enough to enable the provider to transport the resident to the specialist, is a real focus of Kern’s work. It points out a major difference between what rural and urban providers face on a day-to-day basis.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>For instance, his facility has a dental service, called Senior Dental, that comes in to provide oral care, fillings, and cleanings, which alleviates the need for transporting residents to a dentist.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“Not having to jostle residents, especially during the winter months, is a good thing. We have also been fortunate and blessed to have medical providers. In our town of 6,500 there are 10 or 11 medical providers, including MDs, nurse practitioners, and physician assistants,” Kern says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Another perk of being a somewhat larger rural provider is the availability of a five-chair dialysis unit in the general community as well. “I know a lot of small communities that have to transport their residents for dialysis, but we have our own in town,” he says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Facing the Challenges, ​<span>One by One</span></h2> <div> </div> <div> </div> <div> </div> <div>After describing rural providers’ unique challenges in today’s marketplace, the three administrators explain what they are doing to address the problems facing them, notably in the way of staffing.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/DianneEpp.jpg" alt="Dianne Epp" class="ms-rtePosition-1" style="margin:5px 15px;" />For Epp, enticing workers has meant increasing wages to stay in line with the minimum wage of $9 an hour in Nebraska. “At one point, we were barely paying over $9 an hour to our CNAs. So, over the last four years we have increased the base pay, and currently are paying about $13.10 per hour. We have significantly raised wages,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Beyond putting more money on the table, Epp has looked at flexible scheduling for nurse aides, offering eight- and 12-hour shifts. “We offer bailer shifts, double shifts on weekend days and evenings and then you are able to work 32 hours and get paid for 40 hours. This has attracted some staff,” she says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Incentives, Outreach <span>Com​e in Handy</span></h2> <div> </div> <div> </div> <div> </div> <div>Incentive pay is also a tool being used, in which staff picking up additional shifts earn bonus points toward gift cards or maybe a family pass to the Omaha Zoo. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“That has gone over very well and has helped us cut down on some of the scheduling nightmares in trying to keep all of the shifts filled,” Epp says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>To promote the nursing profession, the company also provides scholarships to its CNAs and anyone interested in going into the nursing field.<span style="background-color:initial;"> </span></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Gro​wing Their Own</h2> <div> </div> <div> </div> <div> </div> <div>A key to attracting younger people is to be flexible and know the best shot may be in getting high school students to work before they leave for college, Epp says. The larger communities are all too ready to lure the next generation of workers, she says, and seem to keep a good chunk of them.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“We do provide employment in our community for a lot of high school students and also have some work-based learning experiences where we work with high schools and get some of their students into our facility to get them work experience,” Epp says. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>A majority of Syracuse gradates usually do leave the community, “so it is hard to keep them here unless we have some type of employment that would provide a good wage for them that they could provide for a family on. Scholarships are a good way to entice some high school students and encourage them to possibly go on to nursing.”</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>The effort is all part of a larger push to “grow our own” in Syracuse, she adds, and use the people resources from within their own community.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Competition Brings Wage Pressures​</h2> <div> </div> <div> </div> <div> </div> <div>But, for Neubauer, the administrator who faces the stiff competition from neighboring long term care facilities, the wage pressures are even more intense because of the up-front money being offered to potential employees in a small labor pool.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>“When you have a nursing home down the road that is offering thousands and thousands of dollars for a sign-on bonus and is paying better wages to LPNs [licensed practical nurses], those things are just really hard to compete with,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>To battle back, Neubauer gets what she calls “real creative,” like by installing flexible shifts for employees, which came about after getting input from workers on what steps can be taken to make the jobs more attractive. “When you have staff buy-in, it seems like things go better,” she says. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>Kern sees shift differential pay, especially for hard-to-fill evening and night shifts, as a valuable tool to have available. But, in the dichotomy of the marketplace, his facility is also one that offers the sign-on bonuses and recruitment enticements that other facilities cannot.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>“We also partner with the schools. I go in and talk to our kindergarten kids, kind of a mentoring situation with them to start them early and talk about the elderly and health care,” he says. For older high school students, there are volunteer activities, which sometimes have led to jobs that blossomed into full-fledged careers in the nursing profession.</div> <div>​​​​​<br></div> <div><span style="font-family:georgia, palatino, serif;font-size:1.3em;background-color:initial;"><br></span></div> <div><span style="font-family:georgia, palatino, serif;font-size:1.3em;background-color:initial;">The Hospitals’ Influen​ce</span><br></div> <div> </div> <div> </div> <div> </div> <div>Two aspects of modern health care come up often when talking to rural administrators, one being the access to acute-care hospitals, and two being the use of telemedicine, a growing and potentially significant factor in connecting practitioners to hard-to-reach patients.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div style="text-align:left;"><img src="/Issues/2019/February/PublishingImages/coverstory_rural.gif" class="ms-rtePosition-1" alt="" style="margin:5px 15px;width:436px;height:225px;" />Each of the trio of Good Samaritan administrators says there are clinicians nearby in most cases for their residents to access, but the choices are limited, and oftentimes drives of up to an hour are involved to reach certain specialists or a favored doctor.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>Neubauer says the Alma community does have a critical access hospital, just as Kern’s has. It also offers telehealth, with the goal of expanding the availability of providers in the program, especially in the area of mental health.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>“We have a behavioral health practitioner who is amazing, but overall we have about half a dozen specialty services through that telehealth service. We are looking to expand that number, and that would be a benefit,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>On the hospital issue, Epp says she also has a critical access hospital nearby, a recently built new facility, which can be a double-edged sword at times as it offers skilled nursing care for short-term Medicare stays of 20 days or less.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div>“That short-term stay is of course paid at 100 percent, so that kind of affects our payment” if the patient is in a hospital for that initial period, she says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Making a Career in Spooner</h2> <div> </div> <div> </div> <div> </div> <div>Beyond talk of medical care and staffing challenges, there are those younger professionals who are bucking the trend of moving away from small towns after having left for college. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>One such case is Nicole Danger, a 25-year-old administrator for the Maple Ridge Care Center/The Villas at Maple Ridge in Spooner, Wis., who started at the community when she was 21 and now runs the operation as well as a non-LT/PAC business tied to the property called The Spooner Business Center.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>The 2,700-person town sits “right in the middle” between Duluth, Minn., and Eau Claire, Wis., around 90 minutes from each, she says. The real big city, Minneapolis/St. Paul, is about two hours away from Spooner. The facility has 75 beds, all skilled nursing, with additional services offered that include short-term rehabilitation, hospice, and respite care.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>A connected building has 14 community-based residential facility beds, Danger says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Unlike some rural facilities, Maple Ridge’s census is strong, with occupancy at or near capacity, but that does not mean there are not the challenges of finding qualified workers and provider networks for residents’ specialty care. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“All areas of staffing are difficult, particularly professionals. Therapists are hard to find, registered nurses, LPNs, of course,” she says.</div> <div>​​​​​​​​<br></div> <div> </div> <h2 class="ms-rteElement-H2"><span>The Len</span><span>​</span><span>gth-of-Stay Challenge</span></h2> <p class="ms-rteElement-P"><span></span>While the trend across the industry for large and small providers is for shorter lengths of stay, the issue hits rural operators especially hard, Danger says. “They want patie​nts and residents to have short stays and be back into the community and back to home as soon as possible. With us being in a rural area, that is very difficult because our communities don’t have the support like more urban areas do,” she says.</p> <div> </div> <div>“There is home health, but they struggle with staffing as well. So, we have a patient that could go home but would need home health visits every day or every other day, and home health can see them only twice a week or every third day if possible.”</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/Courtyard.jpg" alt="Good Samaritan, Postville, Iowa" class="ms-rtePosition-2" style="margin:5px 15px;width:280px;height:192px;" />Reimbursement is also part of the struggle, with the main source of payment for Maple Ridge being Medicaid. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“In the rural areas, a lot of the sourcing for the payer is Medicaid. Seventy-percent of my residents are under Medicaid. Of course that makes reimbursement very, very difficult,” Danger says. “We could easily say we are only going to accept so many [residents on] Medicaid, the rest private-pay and Medicare, but ethically that is not serving our community or the needs of our community.”</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Local ​Community is Family</h2> <div> </div> <div> </div> <div> </div> <div>If finding services and workers and more beneficial payment stacks up on the challenges side of the ledger for Maple Ridge, the benefits of being in a small community add up as well. Danger points to her own story, in which she grew up in Spooner and decided to come back and become the head of the nursing facility.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>For Danger, the allure of returning to her roots is all about the connections, and that plays into Maple Ridge as well. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“Our social services director grew up here, I grew up there, so the connections are there, and it is just so broad. If we need something, there are so many people to reach out to,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>The ties within the community have a way of weaving back and forth into lives, because Maple Ridge is the only SNF in town, and the services it offers are a magnet for generations new and old.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“An example is that we have an amazing relationship with our clinic. It is the only clinic in town as we are the only SNF. Five of the doctors working at the clinic work very closely with Maple Ridge Care Center, and 95 percent of our patients are followed by one of them,” Danger says. “They come to our facility, they know our staff.”</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Another benefit is that of course SNFs need to have a good quality rating, and in a small town a good reputation for quality care goes a long way. There is also something to be said for the residents having known Maple Ridge’s caregivers in their lives before they needed nursing care. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“A lot of times residents come here because they want to be in their home town, and they know someone who works here. A lot of residents are like that. My best friend’s grandparents are here and a former teacher from school. Referral sources are made easier because of that,” she says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">The Community Conne​ction</h2> <div> </div> <div> </div> <div> </div> <div>The work done inside the facility has to play well with the general community of Spooner for other reasons, too, Danger says. Namely, since Maple Ridge is a not-for-profit, there is a lot of outreach to the community in the way of fundraising and seeking volunteers to help staff operations and programs. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>And, since the facility is a main employer with 120 workers and a central location for activity, there is a certain spotlight that a small town provider gets that urban counterparts do not.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/February/PublishingImages/Syracuse-Skilled-Nursing-Exterior.jpg" alt="Good Samaritan, Syracuse, Neb." class="ms-rtePosition-1" style="margin:5px 15px;width:281px;height:208px;" />“We are definitely a focal point. There are something like 19 different churches that rotate services for our residents, and we are also very connected to the schools as they have volunteer days as individuals and groups,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Another positive to the rural life of a provider is the opportunity to expand into side businesses as a result of the changes to the population and economic life of a community. For instance, Danger talks at length about her other role in Spooner, which is to run the business center that resulted from the reconfiguration of the nursing care center.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>After a hospital and clinic, in which Maple Ridge resided, departed the complex in 2016 to move to another part of town, Maple Ridge’s owner, Wisconsin Illinois Senior Housing, bought the entire campus and added assisted living to the offering.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“So, in that old clinic space we have leased out the space to 12 different organizations. I don’t manage them, but I sort of act like the commercial landlord. This is huge for Maple Ridge and the community as well,” Danger says.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>Tenants include a new 5,000-square-foot daycare operation, a massage therapy business, and a mental health counseling center, to name a few. “There is a huge variety of things, and with traffic coming into our building, it benefits us. Our building [business center] has been booming in recent years,” she says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Where the Hear​t Is</h2> <div> </div> <div> </div> <div> </div> <div>At the core of it all, which in many ways exemplifies the small-town ethos, is the nursing care provided at Maple Ridge, a place where everybody knows everybody by name, the townspeople know the employees who work there, and the residents are former neighbors.</div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>According to Robert Siebel, president and chief executive officer of Carriage Healthcare Co., which manages Maple Ridge, there is a different level of connection to the residents when in a small town, which is no slight to urban nursing facilities, but just a fact of life in rural America. </div> <div> </div> <div> </div> <div> </div> <div><br></div> <div> </div> <div>“You go to church with them or their families, which makes for a really cool positive for the rural environment,” he says. “The facilities are smaller of course, which tends to make them a little more personal. And, your position in the community is larger, you can influence health discussions because you are, in some cases, the health care in the community.”</div> <div> </div> <div> </div> <div> </div> <div>​</div> <div> ​​</div> ​​​​​As the population of the country steadily shifts to urban areas, both to cities and an ever-expanding sprawl of suburbia, those who remain in small towns often have to adjust to living amongst a shrinking number of people and scarcity of community services.2019-02-01T05:00:00Z<img alt="" src="/Issues/2019/February/PublishingImages/coverstory_t.jpg" style="BORDER:0px solid;" />Caregiving;Management

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