Sixty million Americans—roughly 20% of the population—live in rural areas, according to U.S. census data, but only 11% of physicians and 16% of nurses practice in rural areas. Mortality rates are higher in rural America, too. Delays in emergency care due to transportation time to remote hospital emergency departments can often mean the difference between life and death for rural Americans.

In addition, few rural hospitals can rely on economies of scale, so they are left with higher costs and almost no leverage with health insurers.

These hardships have taken their toll. The University of North Carolina’s Cecil G. Sheps Center for Health Services Research reports that 106 rural hospitals have closed since 2010.

In the face of these persistent barriers to financial solvency, some rural hospitals are taking the initiative, capitalizing on factors they can control to improve access to care as they transition away from inpatient acute care services and toward chronic disease management, population health, and value-based care.

These initiatives come as more attention is being given to social determinants of health. Rural hospitals are asked to contend with even more factors that occur outside hospital walls, such as the poor health outcomes associated with poverty, unemployment, poor nutrition, and lack of care access.

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