Nowhere to go? Nursing home resident hospitalizations fall when rural hospitals close

The closing of rural hospitals results in “significantly” fewer hospitalizations for residents in nearby nursing homes, a sign that those residents may not be able to access the care they need.

A study published in the Journal of Rural Health over the weekend said reduced hospitalizations could have a substantial impact on residents who need any kind of hospital care, whether in an emergency or elective situation.

Researchers at Vanderbilt University and The Cecil G. Sheps Center for Health Services Research at The University of North Carolina at Chapel Hill thought they’d prove that occupancy increased in freestanding nursing homes after rural hospitals with swing beds or skilled nursing units closed.

While that didn’t pan out — occupancy gains were “consistently close to zero post‐closure” — the team discovered that hospital admissions among those in nursing homes jumped by 13%.

At first the change was “moderate” but effects “grew more negative with years after closure,” the researchers reported.

“One reason that closures might result in fewer hospitalizations is due to decreased access to care,” they wrote. “Newly increased distance to services may have made transportation less convenient or accessible and resulted in reduced utilization of hospital services by nursing homes. Our findings cannot describe whether reduced hospitalizations reflect a decline in emergent, urgent and/or elective admissions, but regardless, the impact on nursing home residents could be substantial.”

Brock Slabach, a former hospital administrator who is now chief operations officer for the National Rural Health Association, knows well the interconnected relationships between hospital and skilled nursing facility that are lost when one closes.

Hospitals don’t just admit patients, he said in an interview with McKnight’s Long-Term Care News Monday. They provide tertiary services, ranging from lab work to rounding and medical direction to emergency department visits and, if needed, admissions.

“The continuum of care is fragile in rural communities,” he said. “Increasing distance to a hospital can impact quality, and here, access is a factor of quality.”

The study is believed to be the first examining what effects closures of rural hospitals with skilled nursing components have on local nursing homes. 

Moving pains

One major issue raised by the study authors and Slabach: medical transportation for nursing homes becomes much more difficult when close-by acute facilities shut their doors. It might already take 45 minutes for an ambulance to arrive in a rural area served by volunteers; add an hour-long drive to the next closest hospital and providers have to weigh many more factors before sending a patient out.

There are also challenging logistical and payment issues involved in longer transports, especially if an ambulance has to cross county or state lines with a patient, or if a patient cannot afford the high cost of that longer transport for an elective procedure or fact-finding test not available in the nursing home.

In emergencies, such delay “can lead to worse health outcomes and increased mortality rates,” the researchers noted.

Even in the case of a nursing home wanting to have a patient checked after a fall, long-distance travel has to be carefully considered. The study authors said those kinds of urgent but not necessarily life‐threatening cases “can result in conditions worsening and potentially becoming emergencies.”

While telehealth could be an option for some patient monitoring or to avoid unnecessary emergency room visits, Slabach said it can’t replace the personal touch provided by a nearby, rural hospital.

He said the study was something policymakers ought to consider as they debate how to protect access to rural health. Some 151 rural hospitals have closed since 2010.

In addition to determining that occupancy stayed stable elsewhere after a closure, researchers also found that the percent of Medicare-paying residents and the average ADL scores for residents in local nursing homes remained stable.

But the negative effect on hospitalizations — to be expected even if federal regulators try to discourage them —  are worrying to advocates like Slabach.

“It shows that [rural hospital] closures decrease the systemic approach to healthcare that we have in this country, and it really ultimately affects patients across the system,” he said.