The 15-20 percent of Americans who live in rural areas face greater risks for poor health outcomes. Rural organizations have fewer resources, a smaller pool of providers, and often a poorer patient population responsible for a greater percentage of their bills.

These inequities are rooted in social, economic, racial, and geographic factors that won't be fixed overnight. But dealing with these realities has made rural healthcare organizations innovative and scrappy about how to provide care under challenging conditions.

Here are five things other healthcare organizations can learn from them:

1. Dealing with high patient-pay burden

High deductible health plans (HDHPs) continue to gain market share — in 2018, HDHP enrollment approached almost half of commercially-insured patients. And HDHP enrollment in rural areas is 24 percent higher than in urban areas. Rural provider organizations have had to get creative about how to collect from patients.

At Integrity Family Care, an eight-provider practice in Madison, Alabama, medical coders comb through any unpaid claims of more than $200 looking for insurance errors or incorrect coding that will allow them to resubmit and minimize the patient burden. Then, once they are positive about what the patient owes, they focus on making sure patients understand the details of their coverage and what they owe. “It's about us partnering with them on understanding why they owe it," says Eli Wagner, Integrity's director of operations. Wagner says this often results in payment.

When patients still can't pay, Integrity and other rural practices try to collaborate with patients to set up payments plans, no matter how gradual, to make sure that they continue to collect and maintain their connection with the patient.

2. Off-setting bad debt

Even the best efforts cannot eliminate all the bad debt that comes with higher patient pay. At Iron County Medical Center, a 13-provider hospital in Pilot Knob, Missouri, 60 percent of their bad debt comes from the working poor who have insurance but cannot pay the high deductibles associated with their coverage. In this lead-belt town where mining operations have stopped, many of these patients will never be able to pay — so, Iron County started looking for ways to off-set this inevitable drag on their finances.

Starting in 2014, they began “[rebuilding their] revenue cycle management from the ground up," according to Iron County CEO Josh Gilmore. By examining every step of the process from eligibility to provider documentation, including complex contract terms, Iron County was able to completely overhaul their cost accounting and significantly improve their bottom line.

Gilmore also realized that many of Iron County's contracts had reimbursement levels well below those of Medicare. He had his team embark on a project to review and renegotiate unfavorable contracts. The result was higher operating reserves that insulate Iron County from some of the risk associated with rising bad debt.

3. Re-evaluating staffing models

77 percent of rural areas in America don't have enough physicians to care for all their patients. Big Horn Hospital, a six-physician, critical-access hospital in Hardin, Montana, has been working short-staffed for as long as anyone can remember.

They staff the ER 24/7 with nurse practitioners (NPs) or physician assistants (PAs) at all times, with three physicians on call as back-up. But, for the most part, “the NPs and PAs are very confident, self-assured people" who can handle whatever comes their way, says Kristi Gatrell, Big Horn's CEO. And Big Horn has been careful to provide extra training and support to their NPs and PAs as they serve in this expanded role. "These folks are highly trained and manage all kinds of situations," says Gatrell "from high-level traumas, to cardiac cases, strokes, even the delivery of babies." This kind of shift could take pressure off of physicians even in urban inpatient settings.

4. Leveraging technology creatively

Coteau des Prairies Health Care System (CDP), a 25-bed critical-access and acute-care hospital in Sisseton, South Dakota, staffs its emergency room with a combination of NPs, PAs, and primary-care providers. But they contract with a tele-emergency services provider so they can virtually consult specialists in emergency medicine, behavioral health, and more at the touch of button, 24 hours a day.

Remote specialists can read EKGs, provide second opinions, and even start treatment if one of the few on-site physicians is tied up elsewhere, since they are all fully credentialed at CDP.

This service expands the range of care CDP can provide, improves patient access, and speeds up transfers. An added benefit? CDP finds it is easier to recruit nurses, PAs, and PCPs when they know they have this back-up available and won't be on their own.

The benefits of leveraging telehealth and virtual specialist resources is not limited to rural areas — these tools can help any healthcare organization expand its geographic and medical reach.

5. Get the community involved

As healthcare moves beyond traditional episodic care, the community becomes an increasingly important part of the healthcare equation. Rural health centers — with their close, hometown connections — have a natural advantage when it comes to connecting with patients and organizations outside their walls.

Horizon Health, a 41-provider network of one critical access hospital and five clinics in Central Illinois, started a volunteer community-liaison program to extend its reach and build its reputation. Hospital employee volunteers were recruited to talk to people at soccer games, school plays, and town happenings about Horizon's services and events — sharing information on events, gauging interest and reporting back any concerns they had that Horizon should know about.

At Gibson Area Hospital and Health Services, a regional health system in Illinois, CEO Rob Schmitt takes every opportunity to immerse himself in community life, going to ballgames, parades, and more. “We really support anything dealing with the elderly, kids, or healthcare," Gibson says. When a local school district was planning to cancel all field trips due to lack of funds, Gibson stepped in and offered to sponsor them. It's part of what Schmitt calls his “cradle-to-gave" approach to healthcare.

A similarly close relationship with its community helped Iron County when the organization found itself on the verge of bankruptcy in 2017. Gilmore, the CEO, held a series of community townhalls where he was completely honest about the hospital's situation and asked for partnership and support. The result was a half-cent sales tax promising $350,000 per year to help Iron County stabilize its financial position.

Lia Novotny is contributing editor for athenahealth's Knowledge Hub.