When it comes to rural health, there's no denying that there are demographic and financial challenges that can affect care. But there are also opportunities for improvement, and physical therapists (PTs) and physical therapist assistants (PTAs) need to be ready to advocate for—and when necessary, create—those opportunities. That was the message of a session on rural health care delivered June 14 during APTA's 2019 NEXT Conference and Exposition in Chicago.

The session explored the factors that make rural health care different from health care in more urban areas---factors that in some instances point to the need to rethink how funding is allocated. Presenters pointed to the possibility that the US Centers for Medicare and Medicaid Services (CMS) might be in the early stages of doing just that. Meanwhile, they said, the possibilities for better patient access through telehealth need to be seized in the short-term.

Presenter Jeremy Foster, PTA, boiled down the status of rural health care into a single sentence: "We have all these conditions that are worse in rural settings, but the money's not there."

Foster led attendees through a tour of the demographic elements that create challenges, including a higher percentage of people who describe themselves as having "fair or poor" health compared with those in urban settings, and a generally older population. Other disparities include higher rates of tobacco use, an average annual income gap of $9,242, and life expectancy that averages 2 years shorter than the life expectancy of the urban-dwelling population.

Access to care is, of course, a significant problem in rural areas, Foster explained, and though critical access hospitals (CAHs) often provide high-quality, patient-centered care, current funding systems tend to be based on population more than on need. Under those assumptions, gaps can arise when a smaller population begins to experience conditions that lead to worse health conditions.

This must change, Foster said, because CAHs are providing much-needed care and economic benefits that are worth supporting, including contributing more than $7.1 million to local communities annually through wages and benefits, and providing needed care---an average of 39 million outpatient visits, 809,000 adult hospital admissions, and 82,000 infant deliveries per year.

"There needs to be a lot more research around rural health care," Foster noted, but he added that providers in the rural setting have a responsibility to be "trustees of the money we receive."

Brendon Larsen, PTA, BS, took a deeper dive into the current state of CAHs and rural health care in general, saying that rural health providers are challenged to care for a population that is considered "older, sicker, and poorer" than its urban counterparts.

CAHs’ challenges include an aging infrastructure and a workforce shortage that isn't limited to clinicians, Larsen said, with CAH leaders reporting a 61% shortage in applicants for nonclinical and administrative support positions. At the same time, the type of services provided by CAHs is evolving, with outpatient treatment now making up 60% of CAH gross revenue. The problem, he explained, is that many funding assumptions around rural health care are rooted in inpatient care. When those factors are added to ever-increasing regulatory burdens, CAHs and other rural health providers find themselves struggling to stay afloat at a time when the need for better patient access is increasing---including the need to respond to the nation's opioid crisis.

But could some relief be on the way? Maybe, said Larsen: CMS has formed a Council for Rural Health that is looking at developing a rural health policy initiative. The idea, Larsen explained, is to apply a "rural lens" to CMS programs, with the aim of maximizing providers' scopes of practice, empowering patient decision-making in rural areas, supporting new partnerships, and further expanding telehealth opportunities in rural areas.

Of those potential improvements, telehealth could be of the most immediate benefit, explained Carmen Cooper-Orguz, PT, DPT, MBA. Cooper-Orguz rounded out the program by describing the promise of telehealth, and specifically telerehab, for improving patient access to care.

There are more 'cans' than 'cannots' when it comes to telerehab," Cooper-Orguz told the audience while running through a list of the assessments and treatments that could be accomplished remotely.

The problem, she explained, is that while most providers understand the potential for telerehab, the on-the-ground conditions for providing it need to improve. That will take action from the physical therapy community to advocate for changes to payment policies, state licensing laws and regulations, and provision of rural broadband.

Cooper-Orguz believes one of the most important ways for PTs and PTAs to pave the way for better policy around telerehab is to press for adoption for the Physical Therapy Licensure Compact in all states. By dismantling geographic boundaries to practice, the compact opens up the possibility for increased use of telerehab---but only if compact adoption is accompanied by licensing laws and regulations that permit remote practice, she added.