Introduction
To address workforce needs, Critical Access Hospitals (CAHs) have collaborated with other health care providers, schools and colleges, community-based organizations, and partners with great success. Creating and sustaining partnerships addresses several workforce concerns. Through partnerships, CAHs can address staffing shortages especially when there is a lack of a certain type of health providers in a specific area, such as mental health providers.1 These partnerships can also jointly address workforce training and development while sharing ideas and resources. In addition, when CAHs create partnerships, they are better able to negotiate rates from vendors and insurers (within the parameters of anti-trust laws) to promote financial stability/viability and free up funds for workforce development and retention efforts.2,3 It is vital that CAHs create partnerships for purposes of completing their triennial Community Health Needs Assessment (CHNA) (as applicable for non-profit CAHs) and while making decisions regarding community benefit spending, and both of these activities can promote workforce strategies including recruitment and retention.4 Lastly, CAHs can partner to enhance and expand their Health Information Technology which promotes efficient and quality processes for workforce retention and recruitment.
This module describes nine examples of areas in which CAHs leveraging partnerships is particularly helpful and lists models/examples of these types of partnerships.5 We then describe four types of workforce pathway programs and include examples to provide further resources on establishing and maintaining these programs.
Opportunities to Leverage Partnerships
Staffing Shortages
Staffing shortages remain an issue for rural hospitals overall and CAHs in particular.6 To alleviate this issue, CAHs across the country have created innovative partnerships. In Eastern Colorado, for example, the Eastern Plains Healthcare Consortium seeks to address a nursing shortage by banding together to create a staff sharing program. In this example, nurses can sign up to work extra shifts at member hospitals and they receive grant funds to offset the cost of travel. In Illinois, CAHs have collaborated to create the Illinois Critical Access Hospital Network (ICAHN) in which 58 CAHs share providers such as orthopedists and other specialists that are not needed full-time at a single location.
A specific type of staffing shortage is when certain health or mental health professionals are in short supply. For example, one partnership, Wilderness Health, in northeastern Minnesota and northwestern Wisconsin identified there was a shortage of mental health professionals. To address this shortage, they received a Health Resources and Services Administration (HRSA) grant to give on-demand access to mental health professionals using telehealth. Primary care providers in rural clinics in the region can access the services of mental health professionals and especially focus on evaluations for anxiety and ADHD to alleviate concerns regarding long delays. In addition to addressing the mental health needs of the region, Wilderness Health is an example of providing telehealth across state lines.
Emergencies
Partnerships played a key role in CAHs working together during the height of the COVID-19 pandemic. In Louisiana, six founding hospitals created the Louisiana Independent Hospital Network Coalition which allowed them to share protocols, supplies, and vaccines. Now, 26 hospitals bring staff together to share best practices. CAHs in the coalition jointly credential providers so they can work in one another’s facilities and share access to electronic medical records to help coordinate the care of patients who visit multiple hospitals in the coalition.
In addition to the response to the COVID-19 public health emergency, CAHs often create partnerships to respond to other types of emergencies such as weather events, cyber-attacks, and mass casualty incidents. The Administration for Strategic Preparedness and Response (ASPR) funds Health Care Coalitions (HCCs) to provide resources, tools, and technical assistance that can be used by CAHs for emergency preparedness planning and response capacity while fostering collaborative relationships among hospitals. Examples of Health Care Coalitions include Arizona Coalition for Healthcare Emergency Response, Michigan Healthcare Coalitions, Mississippi Emergency Support Function-8 Healthcare Coalition, Montana Regional Healthcare Coalitions, North Carolina Healthcare Preparedness Coalitions, North Dakota Healthcare Coalition, Pennsylvania Healthcare Coalition, and the Vermont Healthcare Emergency Preparedness Coalition.
Negotiating Rates
Because retention and recruitment of the health workforce requires significant financial resources, finding ways to create partnerships aimed at saving costs on services and supplies can be beneficial. The Louisiana Independent Hospital Network Coalition formed a group purchasing organization which helps secure better rates for members by negotiating purchases of food services, radiology equipment, and other services/supplies. It is important to note that these partnerships must ensure they comply with federal and state antitrust laws that bar independent hospitals from comparing information on what they’re paid by insurers and other types of collaboration that could be considering as hindering competition.
Community Health Needs Assessments and Community Benefit Spending
The Internal Revenue Service (IRS) requires tax exempt hospitals, including CAHs, to conduct triennial CHNAs to create implementation plans and obtain input from public health officials or other community stakeholders.7 Collaboration between CAHs and local health departments could improve CAHs’ ability to identify health disparities and promote health equity. The Chatham Health Alliance in Chatham County, North Carolina demonstrates the efficacy of CAHs working with local health departments to collaboratively plan and coordinate efforts to identify and address local health issues. In addition, Chatham Hospital leadership is an active member of the Chatham Health Alliance demonstrating their commitment to its success.
In addition to triennial CHNAs, CAHs must annually report their community benefit spending to the IRS. Creating partnerships can be helpful when CAHs decide how to spend these dollars. The Rural Wisconsin Health Cooperative, a membership-based organization that fosters collaboration and networking among rural hospitals in Wisconsin, offers technical assistance to members about ways to invest their community benefit dollars to promote affordable housing, childcare, and other infrastructure. The Chief Information Officer of one hospital in the cooperative joined a countywide task force that secured $4 million in funds for broadband. Another member of the cooperative, Door County Medical Center, helped commission a study to identify gaps in housing in the area, and the CEO voiced support for new multifamily housing development. Community benefits are vital for everyone residing in the surrounding community, including hospital employees who require housing, childcare, and other services to ensure they can live and work in rural areas.
Workforce Pathway and Provider Rural Training Programs
There are myriad rural training programs in existence aimed at promoting health professionals working in rural areas. Medical school rural training programs, which may include rural specific curriculum and/or other rural training experiences, are a key example of these rural training programs. We have identified a list of these programs to provide examples.
- University of Missouri School of Medicine Rural Track Elective Program
- University of Washington Targeted Rural Underserved Track (TRUST) Program
- University of North Dakota Rural Opportunities in Medical Education (ROME) Program
- University of Minnesota Rural Physician Associate Program (RPAP)
- University of Colorado Anschutz Medical Campus Rural Program
Other programs include medical residency training programs. HRSA funds the formation of rurally located residency programs under the Rural Residency Planning and Development (RRPD) Program, and several HRSA grantees jointly provide technical assistance for the RRPD Program.
Pathway programs are educational initiatives designed to increase interest in health careers while guiding participants toward careers in the health care workforce. These programs typically offer a structured sequence of courses, hands-on experiences, and/or mentorship opportunities to build the interest and knowledge for various health care professions.8 Community colleges are increasingly partnering with CAHs to create pathway programs, particularly for careers in nursing. These partnerships may be particularly helpful as CAHs may face fewer regulatory barriers in these partnerships than they experience with larger, multi-campus universities. Two examples of community colleges partnering with CAHs are listed below. Both of these examples were discussed in interviews with the Flex Monitoring Team.
- Nevada Rural Hospital Partners (NRHP): In 2022, NRHP created the Nurse Apprenticeship Program using funds from the American Rescue Plan Act (ARPA) which uses three mechanisms to address nursing shortages in Nevada’s 13 CAHs: (1) They reimburse facilities for the hourly rate of their nursing students, (2) They reimburse facilities for a signing bonus if they hire the nursing student after graduation, and (3) They reimburse students for travel, meals and lodging. More than 700 nursing students have participated and about one-third have been hired by their facility post-graduation.
- Clay County Hospital and Medical Clinics in Illinois: In 2023, they began a nurse apprenticeship program in partnership with Illinois Eastern Community Colleges. For the first year of the apprenticeship, apprentices serve as Certified Nursing Assistants (CNAs). In the summer following their first year, they take a Licensed Practical Nurse (LPN) course and then work as an LPN in the second year of the apprenticeship while they are completing their Registered Nurse (RN) coursework.
Area Health Education Centers (AHECs) focus on increasing the supply of health care professionals in rural and underserved areas with a focus on primary and preventive care. They are funded through the HRSA Bureau of Health Workforce and their directory can be found at this link.
Other examples of rural pathway and rural training programs using HRSA and AHEC funds include:
- Rural Experiences for Health Professions Students, which is based in South Dakota and raises awareness for health care needs in underserved areas of South Dakota while also coordinating placement for health professions students.
- Project PROMISE (Providing Rural Opportunities in Medicine though Inspiring Service and Education) is an experiential pathway program in North Carolina. It provides high school seniors with medical academic training, mentors, and experiences in North Carolina medical facilities.
- FORWARD NM (Frontier and Rural Workforce Development New Mexico Pathways to Health Careers) supports pathway programs for middle and high school students as well as college and graduate students.
- The University of Missouri AHEC supports numerous programs including those for youth considering health careers as well as rural health professional training programs.
Conclusion
To address the complex challenges associated with recruitment and retention of their workforce, CAHs can strategically leverage partnerships with other health care providers, educational institutions, and community organizations. Through these partnerships, CAHs can effectively mitigate staffing shortages, enhance workforce training, and improve financial stability. These collaborations not only facilitate access to specialized care and resources but also empower CAHs to create robust workforce pathways. Additionally, by engaging in partnerships for CHNAs and community benefit spending, CAHs can ensure that their workforce strategies are aligned with broader community health goals. Ultimately, these efforts contribute to the creation of a stable and competent workforce, which is essential for delivering high-quality care in rural communities.
Appendix
This appendix lists all resources referenced in the above module, organized according to the module headings. This appendix also features additional resources that were not included in the module. Each of the listed resources includes a description and link to the corresponding resource.
Staffing Shortages | ||
|---|---|---|
| Resource | Description | Link |
| Eastern Plains Health Consortium | This consortium seeks to address a nursing shortage by banding together to create a staff sharing program. In this example, nurses can sign up to work extra shifts at member hospitals and they receive grant funds to offset the cost of travel. | https://www.easternplainshealth.org/ |
| Illinois Critical Access Hospital Network | Fifty-eight member CAHs share providers such as orthopedists and other specialists that are not needed full-time at a single location. | https://icahn.org/ |
| Wilderness Health | This organization identified a shortage of mental health professionals in northeastern Minnesota and northwestern Wisconsin. To address this shortage, they received a Health Resources and Services Administration (HRSA) grant to give on-demand access to mental health professionals using telehealth. | https://wildernesshealthmn.org/about/staff/ |
Emergencies | ||
|---|---|---|
| Resource | Description | Link |
| Health Care Coalitions: A Resource to Support Critical Access Hospital Emergency Preparedness Planning | This brief details examples of Health Care Coalitions created to address emergencies such as weather events, cyber-attacks, and mass casualty incidents. | https://www.flexmonitoring.org/publication/health-care-coalitions-resource-support-critical-access-hospital-emergency-preparedness |
| Louisiana Independent Hospital Network Coalition | This coalition was originally founded during the height of the COVID-19 pandemic to share protocols, supplies, and vaccines. The coalition has since expanded, and now includes 26 members who collaborate on best practices, jointly credential providers, and share access to electronic medical records to help coordinate the care of patients who visit multiple hospitals in the coalition. | https://www.lihnc.org/about |
Negotiating Rates | ||
|---|---|---|
| Resource | Description | Link |
| Louisiana Independent Hospital Network Coalition | This coalition formed a group purchasing organization which helps secure better rates for members by negotiating purchases of food services, radiology equipment, and other services and supplies. | https://www.lihnc.org/about |
| Statements Of Antitrust Enforcement Policy in Health Care | This statement was issued by the U.S. Department of Justice and Federal Trade Commission and describes federal policies on antitrust enforcement and detailing permissible joint activities between health care organizations. | https://www.justice.gov/atr/statements-antitrust-enforcement-policyin-health-care |
Community Health Needs Assessments and Community Benefit Spending | ||
|---|---|---|
| Resource | Description | Link |
| Chatham Health Alliance | This organization works with local health departments to collaboratively plan and coordinate efforts to identify local health disparities and advance health equity in their community. | https://www.chathamhospital.org/ch/about-us/comunity-health-needs-assessement/ |
| Rural Wisconsin Health Collective (RWHC) | The RWHC, a membership-based organization that fosters collaboration and networking among rural hospitals in Wisconsin, offers technical assistance to members about ways to invest their community benefit dollars to promote affordable housing, childcare, and other infrastructure. | https://www.rwhc.com/ |
Workforce Pathway Programs | ||
|---|---|---|
| Resource | Description | Link |
| Addressing the National Rural Health Care Worker Shortage with a Focus on Kindergarten Through 12th Grade Educational Strategies – National Rural Health Association | This policy brief discusses the importance of employing educational strategies in the K-12 setting to inspire and prepare rural students for careers in health care. It also explores the potential to develop partnerships and mentorship programs to overcome barriers and build a sustainable rural health care workforce. | https://www.ruralhealth.us/getmedia/47a40e1e-e08a-46b8-a0a3-00037dd998f9/2024-NRHA-Rural-Workforce-Pathway-Programs-policy-brief.pdf |
| Frontier and Rural Workforce Development New Mexico Pathways to Health Careers (FORWARD NM) | This initiative supports health career pathway programs in New Mexico for middle and high school students as well as college and graduate students. | https://www.ruralhealthinfo.org/project-examples/724 |
| Missouri Area Health Education Centers (AHEC) | This AHEC supports numerous programs including those for youth considering health careers as well as rural health professional training programs. | https://mahec.org/ |
| Nevada Nurse Apprentice Program – Nevada Rural Hospital Partners (NRHP) | NRHP utilized funds from the American Rescue Plan Act (ARPA) to address nursing shortages in Nevada’s 13 CAHs by establishing an apprenticeship program that included reimbursement to facilities for the hourly rate of their nursing students and signing bonuses for any nursing students they hire post-graduation. This program also reimburses nursing students for travel, meals, and lodging. | https://nap.nrhp.org/ |
| Nursing Apprenticeship Program Example – Clay County Hospital | This program was established in partnership with several local community colleges. For the first year of the apprenticeship, apprentices serve as Certified Nursing Assistants (CNAs). In the summer following their first year, they take a Licensed Practical Nurse (LPN) course and then work as an LPN in the second year of the apprenticeship while they are completing their Registered Nurse (RN) coursework. | https://iecc.edu/iecc/iecc-and-clay-county-hospital-create-first-its-kind-nursing-apprenticeship-program |
| Providing Rural Opportunities in Medicine through Inspiring Service and Education (Project PROMISE) | Project PROMISE is an experiential pathway program in North Carolina that provides high school seniors with hands on workshops, mentors, and job shadowing in medical facilities across the state. | https://mahec.net/rhi/project-promise |
| Rural Experiences for Health Professions Students (REHPS) | REHPS is a program based in South Dakota which raises awareness for health care needs in underserved areas of the state while also coordinating placement for health professions students. | https://www.ruralhealthinfo.org/project-examples/731 |
Rural Training Programs | ||
|---|---|---|
| Resource | Description | Link |
| Missouri Area Health Education Centers | This AHEC supports numerous programs including those for youth considering health careers as well as rural health professional training programs. | https://mahec.org/ |
| North Dakota Rural Opportunities in Medical Education (ROME) | This 20–24-week program pairs medical students at the University of North Dakota with rural family medicine preceptors and allows students to learn about practicing in rural primary care. | https://www.ruralhealthinfo.org/funding/4456 |
| Rural Residency Planning and Development (RRPD) Program | This program, funded by HRSA, seeks to improve access to health care in rural communities by supporting rurally-located residency programs across the U.S. to address workforce shortages. | https://www.grants.gov/search-results-detail/349410 |
| RuralGME.org | This website, operated in partnership with the North Carolina Area Health Education Center and several academic partners, is funded by HRSA to provide technical assistance related to the Rural Residency Planning and Development (RRPD) Program. | https://www.ruralgme.org/ |
| University of Colorado Rural Program | This is a program available to medical students at the University of Colorado who wish to practice in rural communities. The Rural Program allows students to experience first-hand what it is like to serve a rural community and provides training and skills to help them effectively practice in the rural setting. | https://medschool.cuanschutz.edu/education/current-students/curriculum/tracks/rural-program |
| University of Minnesota Rural Physician Associate Program (RPAP) | This program allows University of Minnesota medical students to train in rural settings, giving them the opportunity to understand individual patients’ social drivers of health and to become personally engaged with a smaller community. | https://med.umn.edu/rpap |
| University of Missouri School of Medicine Rural Track Elective Program Opportunities | This program is funded by a grant through the Missouri Department of Health and Senior Services to expand opportunities for medical students and residents at the University of Missouri interested in rural health care. It offers nine rural track medical student electives including child health, emergency medicine, family and community medicine, obstetrics and gynecology, and surgery. | https://www.ruralhealthinfo.org/project-examples/1044 |
| University of Washington Targeted Rural Underserved Track (TRUST) Program | This program trains University of Washington medical students in rural and underserved communities throughout Alaska, Washington, Idaho, Montana, and Wyoming. This program pairs students with experienced preceptors helping them integrate into the system, build strong connections at their continuity sites, and develop relationships with community members. | https://www.ruralhealthinfo.org/project-examples/780 |
References
1. Rural Mental Health. Rural Health Information Hub. June 7, 2024. Accessed June 10, 2024. https://www.ruralhealthinfo.org/topics/mental-health#workforce-challenges
2. About LIHNC. Louisiana Independent Hospital Network Coalition. Accessed June 10, 2024. https://www.lihnc.org/about
3. United States Department of Justice. Press Release: Justice Department Will Not Challenge Formation of Rural Hospital Network in Wisconsin. November 12, 1996. https://www.rwhc.com/papers/DOJ_.html
4. Gale J, Croll Z, Zoll L, Coburn A. Critical Access Hospitals’ Community Benefit Activities: An Updated Review.; 2018. https://www.flexmonitoring.org/publication/cahs-community-benefit-activities-updated-review-fmt-briefing-paper-40
5. Hostetter M, Klein S. How Regional Partnerships Bolster Rural Hospitals. The Commonwealth Fund. May 15, 2023. https://doi.org/10.26099/qzfe-xh41
6. Rural Healthcare Workforce. Rural Health Information Hub. April 19, 2024. Accessed June 10, 2024. https://www.ruralhealthinfo.org/topics/health-care-workforce
7. Community Health Needs Assessment for Charitable Hospital Organizations - Section 501(r)(3). Internal Revenue Service. July 1, 2024. Accessed August 16, 2024. https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3
8. Teherani A, Uwaezuoke K, Kenny J, et al. Aspiring Physicians Program: Description and Characterization of the Support Processes for an Undergraduate Pathway Program to Medicine. Medical Education Online. 2023;28(1):2178368. doi:10.1080/10872981.2023.2178368