Those who have lived in a rural area know there’s something special about these communities. People in rural areas can often count on each other, and they value hard work and collaboration. Nate Schema, president and CEO of the Good Samaritan Society, said of rural settings, “We’re serving retired teachers, farmers, pastors, business owners, and veterans. These are proud communities, where people wake up every day and think about how they can better not only their families but their communities.”

He added, “We are at a crossroads right now, but we have an opportunity to look at unique ways to continue to serve rural communities and ensure their sustainability.”

The State of Rural Long Term Care

In many ways, residents in rural long term care facilities are like their counterparts in urban and suburban communities. However, according to Nursing Homes in Rural America: A Chartbook, released by the Rural Policy Research Institute (RUPRI), rural residents are more likely to have their costs reimbursed by Medicaid, a diagnosis of dementia, psychiatric illness, mental or behavioral health needs, and/or depression. Interestingly, while most of these residents are over age 85, they are less likely to need assistance with activities of daily living than their urban counterparts. They also tend to require less complex care, although they have higher rates of cognitive impairment and behavioral issues.

As in many communities across the country, rural dwellers express a preference to age at home. In a survey from 2021, 62.5 percent of rural respondents said they prefer to receive long term care services in their homes. However, as in many parts of the country, access to home care services and support may be challenging to obtain. Lack of transportation often is the greatest barrier between older adults and their receiving care at home. Other challenges include lack of access to health care services and workforce shortages. Increased funding and improvements in health care and transportation are necessary to address these barriers, but it emphasizes the importance of long term care facilities continuing to serve elders in rural communities.  

Unfortunately, many rural nursing homes are struggling to survive. According to a report from the RUPRI Center for Rural Health Policy Analysis, “a higher proportion of nursing homes in rural areas have closed compared to urban areas between 2008 and 2018. Many rural residents rely on rural hospitals with swing beds for both post-acute care and long term care services, but the closure of many hospitals in rural areas may potentially leave residents with few to no options to care.”¹ In the end, the report said, nursing homes remain the backbone of rural long term care and the only option for some older adults.

The Challenges and Opportunities

Rural nursing homes take their roles very seriously, despite the challenges they face. “We have often found that our Good Samaritan locations are a focal point and the health care hub within their rural communities. They are a vital part of the economic engine of the community. They work closely with the local pharmacy, which might be the only one in the area,” said Schema.

If a rural care facility closes, the nearest alternative might be hundreds of miles away. “We see our role as vital and our facilities’ sustainability as a top priority,” Schema said.

Yet, the challenges are real, especially when it comes to finding qualified caregivers in rural communities. For instance, Nikki Wegner, president of the North Dakota Long Term Care Association, said, “The staffing mandate is clearly a challenge. We simply don’t have enough RNs [registered nurses] to be on-site 24/7. States like North Dakota rely on contract nursing staff already, and that drives up costs even higher than they are already. If we could get the nursing staff we need through immigration that we’ve been waiting on since 2021, that would help us tremendously.”

Employing nurses and other workers from outside the United States is a key strategy to address staffing shortages in rural areas. However, that may be easier said than done.

Kenneth Scott Jr., DO, CMD, CEO of SilverSage Management Services, said, “We’re all ready to go on this, but we’ve been stymied by the federal government. It’s taking us three to four years to get somebody in from another country.”

More immigrant workers, he said, would provide an effective solution to staffing shortages in rural areas. For instance, he said, “we have a large pool of nurses in the Philippines who would love to come here and practice, and they’ve already passed U.S. boards.”

Brock Sherva, CEO of Northwood Deaconess Health Center in North Dakota, said that in rural areas, “you’re trying to walk this fine line between what your community needs and compliance with federally regulated scope of what you can offer, and then somehow try to pay for it all.”

He observed that there is also a push to embrace new technology to streamline various tasks and maximize data collection. “We’re all just trying to do the best for our communities and the residents we serve,” Sherva said.
With facilities unable to find staff to care for more residents or shutting down because they can’t stay financially feasible, it sometimes seems that families are playing musical chairs with their loved ones—especially in rural areas, where there are fewer and smaller nursing homes.

“We’re scrambling today because we have lost facilities around the nation, and, at the same time, consumers are starting to trust nursing homes again post-COVID and scrambling to get their loved one into a facility, where there are fewer beds,” said Sherva. Families in this situation often end up on a waiting list for a nearby facility, where it might take months for placement, or they have to take their loved one to a nursing home many miles away.

He added, “We’re just getting bombarded with referrals, but we can’t take everyone; and some people have to go elsewhere.”

Because rural facilities are so woven into the fabric of the community they serve, one key to their survival and the ability to provide excellent care and services involves community partnerships. Schema explained, “We want to make sure that we’re inviting other groups into our locations, whether that’s local schools, businesses, or others. We want this to be a source of pride for that local community, and we need our community support to be sustainable.”

For instance, Good Samaritan has a meals-on-wheels program that serves older adults in the area. “It’s a bit unconventional and doesn’t operate the same as it would in an urban area, but it keeps residents in the community a bit longer and helps ensure they get adequate nutrition,” he said.

Wegner stressed that rural facilities can’t function in a silo. “Our state chapter helps [the facilities] network with one another so they’re able to share their challenges, solutions, and best practices. They can talk about the successes they’ve had and resources they’ve found useful,” she said. “Our association does a lot of education for our providers, and we’re always trying to identify topics and content that are important to them.”

Connections Across the Miles

Often, rural families travel 30 minutes or more to visit a loved one in a nursing home. If the loved one’s facility closes, that hardship is exacerbated. Many rural facilities have come to rely on technology to help connect residents and families, but that’s not always an ideal solution. “One thing we learned through the pandemic is that technology is not a replacement for those one-on-one connections, and that residents suffer when they don’t have personal interactions,” Schema said.

While his organization invested in one thousand iPads to enable residents to connect with their families by videoconference, Schema and his team continue to look at opportunities to facilitate personal engagement. For instance, they have guest suites and rooms where family members can stay when they travel for visits.

Sherva noted, “We have an independent apartment complex that’s attached to our building, and we have three that can be reserved at all times for families so they can stay here at no charge and spend time at the facility with their loved one.” He suggested the importance of helping families understand that even though they may be farther away from their loved one, that person will be in a facility getting the best possible quality of care, and personal well-being will be prioritized.

Schema shared, “We are constantly working with churches, schools, and other local groups to bring people in to ensure our residents feel like they’re part of the community. In many cases, our residents are people who helped build the community. We feel a responsibility and obligation to ensure that in their final years, they are valued.”
When visiting a loved one is challenging because of distance, Wegner suggested that families spread out visits. “One person can go this week, and someone else can go the next. Then they coordinate holidays to ensure their loved one isn’t alone without placing undue burden or stress on the whole family,” she said.

She added that there are reliable volunteers in many communities, so families can reach out to them and introduce themselves and their loved one. Facilities even can start programs to “adopt a grandparent” to ensure all residents have someone to connect and engage with regularly.

Of course, while all these ideas are useful, they are not a definitive answer to addressing time constraints when a loved one is in a rural nursing home. Sherva said, “We’ve always had a great group of volunteers from area churches, women’s clubs, etc., but everyone is busy and has limited time.”

Additionally, there is only so much volunteers can do. For instance, they can’t move a resident or perform some caregiving tasks because of liability risks.

Nonetheless, ensuring that families have connections with their loved one and that residents are engaged needs to be a focus in rural facilities as, unfortunately, this challenge is likely to increase—at least for the short term. Wegner said, “We have had six nursing homes close in a 35-month period. When these closures happen, it can create a significant hardship for families when the nearest setting for their loved one is hundreds of miles away.”

This may lead some families to bring their loved ones home; and while Wegner noted that there are growing resources for family caregivers and home care, one’s home often isn’t the best or safest setting for individuals with significant health care needs.

Shortage of Services

Getting specialists into rural communities has long been a challenge, and it continues to present an obstacle to accepting and attracting referrals. While some mental health and other services can be provided via telehealth, other efforts require in-person exams and treatments.

Schema said, “We partner with mobile dental services that visit residents at our locations regularly. We’ve had quite a bit of success with this.”

Some rural areas are starting their own specialty units. For instance, in Howard Lake, Minn., there is a specialized program to serve post-cardiac surgery patients. Outside of Sioux Falls, S.Dak., in Canistota, a town of about 600 people, specialized behavioral health services are offered.

Schema said, “We have to think about how we invest and ensure that those communities are sustainable and viable. We have to address the issue that it could take upwards of a year or more to fill a clinical position in a small rural community. We need a way to attract and keep good staff in these settings without a prescriptive, one-size-fits-all staffing requirement that hinders our ability to provide care in these rural areas.”

Sherva said, “You need to reach out and try to establish relationships with the closest dentist, optometrist, etc. It’s all about community building and making meaningful connections with practitioners, service providers, and others in the area. We also have a fleet of vans that drive patients and residents to appointments if we’re not able to get these in-house.”

Community leaders and employers also can partner to promote their rural community to dental, ophthalmology, medical, nursing, podiatry, and other schools as good places for graduating students to live and work. They could consider partnering with others in the community to offer incentives such as rental discounts and assistance with closing costs for homes.

“We’ve partnered with one of the big nursing schools in the state, and now a rural rotation is required. We need to establish something like this for dental and other students so they can see how they can truly make a difference in a rural community,” said Sherva.

Seeking Solutions

While rural facilities are surviving with the support of their communities, many also are working with state and national organizations on more permanent solutions. “We need states to invest in Medicaid reimbursement, especially in areas that have some of the lowest rates in the nation. We need to see increased investment in these rural areas where we’re seeing extraordinary inflation,” Schema said.

There is some awareness of the needs and challenges of rural facilities among policymakers. Schema noted that Governor Jim Pillen in Nebraska and Governor Kim Reynolds in Iowa started a letter signed by governors across the country warning the federal government about the negative impact a one-size-fits-all staffing rule is likely to have. In South Dakota, lawmakers convened a summer study to address the need to ensure rural communities are sustainable now and ten to fifteen years down the road. “We need sustained focus and energy on the state and federal levels to make sure we have the predictability all providers are looking for,” Schema said.

Partnerships and collaborations are showing promise. In North Dakota, a clinically integrated network called the Rough Rider High Value Network, comprising twenty-three independent critical-access hospitals, acts as an accountable care organization to change how care is delivered throughout the state, including in rural areas. “It’s relatively new, so I can’t say that we’re seeing benefits or drawbacks yet; but I think it’s a promising way to deliver care as we move more into the world of value-based medicine,” said Sherva. He noted that rural areas need to think outside the box for ways to keep from losing much-needed nursing homes and hospitals.

Opportunities and Optimism

Like their residents, many of whom have overcome challenges and faced adversity with courage and confidence, rural facilities look ahead with optimism. Schema said, “I think rural communities have an opportunity. They have to continue to look to engage the broader community. They can’t look inward and think they’re going to solve everything on their own.”

He suggested the importance of telling their stories, getting involved with local community organizations, engaging with state legislators, and inviting people into rural communities to meet and get to know residents. “We can’t put our heads in the sand and think that others will solve our problems for us. We need to be our own advocates for those we serve,” he said.

These connections are increasingly important, as more areas are seeing natural disasters such as tornadoes, floods, and wildfires. Schema said, “Recently we saw anywhere from seventeen to twenty-five inches of rain in southwest Minnesota and northwest Iowa. Fortunately, none of our Good Samaritan locations had to evacuate; but we had dozens of employees who were affected and many who couldn’t make it to work for days and upwards of weeks because of the devastation. During these times, we see the best in our rural communities. 

We’ve been blown away by the lengths that people have gone to, whether it’s neighboring communities pulling up local food trucks and providing a free meal, to people coming in just to help with sandbags. You see the pride of rural communities coming together in those moments. We need to continue to engage and reach out and let everyone know how appreciative we are and how committed we are to caring for their loved ones. It is a privilege to serve them.”

References
1.  RUPRI Center for Rural Health Policy Analysis, Nursing Homes in Rural America: A Chartbook, (Rural Policy Research Institute, July 2022), https://rupri.org/wp-content/uploads/Nursing-Home-Chartbook.pdf​