NC Maps a More Sustainable Future for Rural Healthcare
- Robert Jones
- 15 minutes ago
- 4 min read
It’s official. After nearly two years of painstaking research and analysis, RHI has submitted its Rural Healthcare Sustainability Blueprint to the North Carolina General Assembly.
To the best of our knowledge, no other state has ever funded such an ambitious project for creating “effective models of sustainable healthcare for rural communities,” to quote the legislative language authorizing the work. (See the announcement here.)
With 3.5 million residents spread across 78 rural counties, North Carolina is home to the second-largest rural population in the United States. Along with that large population comes a pressing need: the state has suffered the nation's third-highest number of rural hospital closures since 2005.
In 2023, the General Assembly recognized that a different approach was needed – one that moved beyond crisis management to strategic, data-driven planning. The Blueprint that we delivered last week reimagines a healthcare continuum designed to be the most effective for patients and the most financially sustainable for providers.
Importantly, the Blueprint could also serve as a model for states trying to secure their share of $50 billion in federal funding for rural healthcare.
A Multi-Phase Research Approach
Our work for the State of North Carolina took a uniquely comprehensive approach, combining deep quantitative analysis with extensive community engagement. The research unfolded in several key phases:
Mapping the Landscape: Recognizing that rural residents don't limit their healthcare to county boundaries, we organized the 78 counties into 22 regions based on current, proven patterns of commuting, commerce, hospital admissions, and more. This wider view was crucial for developing realistic sustainability models.
Quantifying Resources: We created the first-ever comprehensive inventory of healthcare resources across all 78 rural counties, cataloging nearly 50 different types of facilities and providers, including hospital beds, operating room, primary care providers, and dozens of medical and surgical specialties.
Understanding Past, Present, and Future Utilization: The heart of our Blueprint development involved a comprehensive analysis of historical healthcare utilization patterns and future projections, followed by sophisticated optimization modeling to determine the ideal mix and distribution of healthcare facilities. Over the course of a year, we analyzed 70 gigabytes of data, including 1.6 million inpatient encounters and 47.2 million outpatient encounters.
Listening to Communities: Numbers don’t lie, but we also wanted to hear the experiences and expectations of rural stakeholders. We conducted 12 listening sessions across geographically diverse counties and surveyed more than 1,600 rural residents to understand their healthcare preferences preferences. This grassroots approach ensured that data-driven conclusions aligned with real-world community needs.
Key Findings That Challenge Assumptions
The research revealed eight insights that may challenge conventional wisdom about rural healthcare. For instance:
More Beds Don't Equal Better Health: Contrary to popular belief, rural counties with the least desirable health outcomes actually have the highest numbers of acute care and emergency department beds per capita. This suggests that simply adding more hospital capacity isn't the answer – the real issue is how resources are distributed and utilized.
Patients Prioritize Quality Over Convenience: For inpatient care, an overwhelming 85% of survey respondents said they would drive up to an hour for a hospital with greater expertise rather than choosing a local hospital with less specialized care. This finding supports a model where some facilities focus on higher-complexity care while others provide essential but less specialized services.
Regional Thinking Is Essential: Only 47 of the 78 rural counties can individually sustain a hospital, but when viewed regionally, the picture changes dramatically. Many areas where individual counties lack sufficient demand can support shared healthcare infrastructure when county lines are considered more flexibly.
The Blueprint: Customized Solutions for Each Region
The output of all this research is a series of detailed Blueprints for each of North Carolina’s 22 rural regions. Rather than a one-size-fits-all approach, each regional Blueprint considers local population characteristics, existing resources, and realistic market conditions.
Each Blueprint seeks to optimize the healthcare delivery continuum – eight different types of access points, ranging from primary care practices to regional referral centers. Rather than fixed and immoveable features of the landscape, we treat these access points as “levers” that can be adjusted to achieve the goals of proximity, complexity, and stability.
Based on healthcare effectiveness and sustainability, each region received three scores: 1) a measure of the current state; 2) the likely trajectory with no intervention; and 3) potential improvement if the Blueprint is implemented. For example, several regions that currently score in the 40s and 50s due to a mismatch between healthcare needs and services could see their scores improve into the 70s and 80s through strategic resource reallocation.
Why It Matters
When we started this project in late 2023, we could never have envisioned completing our work just as the federal government began taking applications for $50 billion in funding under the new Rural Health Transformation Project (RHTP). We believe that North Carolina is now uniquely positioned to claim discretionary funding based on its foresight in commissioning the Rural Sustainability Blueprint.
For other states, the North Carolina work has provided RHI with deep, data-driven insights into all 8 of the domains required for RHTP applications:
Improving access to hospitals, other health care providers, and health care items and services
Improving health care outcomes of rural residents
Prioritizing new and emerging technologies for prevention and chronic disease management
Fostering strategic partnerships between rural hospitals and providers
Enhancing economic opportunity and supply of health care clinicians
Prioritizing data and technology-driven improvements
Outlining strategies for long-term financial solvency
Identifying specific causes driving rural hospital closure risks
As a mission-driven nonprofit, we would be delighted to offer pro bono assistance to states applying for RHTP funding. If you have questions – including data sources, resource mapping, accessibility measures, hospital essentiality, scoring methodology, and more – please contact us here.
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