Rural and Community Health Institute celebrates 20 years of supporting rural health care

We are all connected to rural America. Rural Americans grow the food we eat and the cotton fiber for our clothes. They mine critical minerals and drill fuel for our homes and vehicles. They preserve and manage wildlife. They keep hunting, fishing, camping and hiking retreats ready when it’s time for urbanites to leave the city. They are, in many ways, the backbone of our nation. But when things go wrong, it can take hours for rural Americans to reach help. And in a medical emergency, minutes can make a big difference.

The Texas A&M Health Rural and Community Health Institute (RCHI) has been supporting rural health care for 20 years. During that time, the need for RCHI’s help has only heightened. Since RCHI was established in 2003, nearly 200 rural hospitals have closed in the United States and hundreds more face closure in the near future.

Applying the land-grant approach to health care

RCHI was founded under the leadership of Nancy Dickey, MD, a visionary physician who recognized the challenges of rural health care and created solutions to improve the quality of care in rural communities. Dickey is a family physician by training who practiced in a small town for many years before joining the Texas A&M University Health Science Center (Texas A&M Health) in 1999. She was also the first woman to be elected president of the American Medical Association (AMA). During her tenure at the AMA, she said patient safety was a major focus of the organization and something she and a colleague were determined to address in rural communities.

“As the Rural and Community Health Institute was approved by the Texas A&M System Board of Regents, we were committed to taking the land-grant philosophy out to small-town medicine,” Dickey said.

Land-grand universities were formed to take the agriculture and engineering science being developed in the university out to the people engaged in those activities every day. Extension agents, for example, teach farmers how to yield a better crop based on the research being conducted at the university. At Texas A&M, those activities are done through the AgriLife Extension Service and the Engineering Extension Service. The Rural and Community Health Institute was established with that same intent—to extend the university’s advanced knowledge about health care to medical facilities in rural areas.

“If you take the philosophy that says, in theory, we here at the university are examining those issues of safety, new technology, new diagnostics and new treatments, how do we take that out to small towns? As we got there, we discovered that, yes, there’s a piece of that, but it’s much less about the technology of medicine than it is about the delivery system of medicine,” Dickey said.

The vital role of rural hospitals

Modern medical technologies often require large teams of very specialized health care professionals with access to advanced, expensive equipment. Small-town facilities that support smaller populations cannot afford to acquire this kind of equipment or recruit and hire those advanced professionals. Even providing the level of care they are equipped to deliver can be difficult since many rural Americans do not have health insurance or the means to pay for that care. In the face of such challenges, many rural hospitals have been forced to close their doors.

Rural hospitals are still important, though. Texas has the nation’s largest rural population at about 4.7 million people. Even those who do not live in rural areas may have family members who do. In addition, urban residents often spend time pursuing recreational activities in rural areas and many travel through rural communities on roads that connect to large cities. If those travelers are involved in a car crash or recreational-related injury such as a hunting accident, they’ll likely find themselves being stabilized in a rural hospital before being transported if needed to a larger facility for more extensive care.

Rural hospitals are also major employers in their communities and contribute greatly to local economies. Adam Willmann ‘05, the president and CEO of Goodall-Witcher Healthcare in Clifton, Texas—a town about 35 miles northwest of Waco—says his hospital is vitally important to the entire county it serves. With a population of about 3,500, Clifton is the largest city in Bosque County.

“Goodall-Witcher is the largest employer in Bosque County. We have about 250 employees and a payroll that’s over $18 million, so we are the largest industry here,” Willmann said. “Those employees have a trickle-down effect, from the schools to the other businesses they support. We are also trying to be the leader in the community by supporting other businesses, other organizations in town or in the county, because we’re not just a hospital in Clifton, we are a Bosque County hospital.”

When a hospital closes, the ripple effects crush communities. The Texas Organization of Rural & Community Hospitals (TORCH) reported that, on average, rural hospital closures cost 170 jobs and an annual payroll of $22 million. Those losses hurt local businesses, lead to reduced sales tax revenue and shrink school enrollment numbers, which drive down state payments to local schools. Texas leads the nation in rural hospital closures, with 29 facilities shuttered since 2005.

Supporting rural health

Willmann says his hospital’s challenges are not unique. Like other health care facilities—rural and urban alike—he says recruiting quality health care providers is becoming increasingly difficult. But that is compounded in a small community with limited housing availability. This problem, as well as quality improvement, patient safety and continuing education, are all issues RCHI has helped Willmann and other rural hospital administrators tackle. Through the Quality/Patient Safety Series, for example, RCHI connects rural health professionals from around the nation to discuss issues, share advice and bounce ideas off each other.

“It’s a network. It’s not just, what is Goodall-Witcher in Clifton, Texas, facing, but what are other small towns in Nebraska or Maine facing and what are they doing? So RCHI, through this program, has allowed us to really network with small hospitals across the nation so we’re able to develop or fine-tune some of our thoughts and solutions to our problems to maybe make them better,” Willmann said.

“Rural health care continues to be challenging in many respects,” said RCHI’s current executive director, Kia Parsi, MD. “You have limited resources and a smaller group of clinical team members to provide care for an entire community.”

Parsi joined RCHI as the executive director in November 2022. Before that, he worked as a rural physician for 18 years and as a chief medical officer for seven years.

“RCHI’s mission is to identify the needs of rural communities and find solutions that are specific to those needs,” he said. “These needs guide the vision and strategy of RCHI’s plans related to supporting rural and community health.”

One of the first challenges RCHI addressed was peer review, which is a process where physicians and other practitioners evaluate each other’s performance and quality of care. In rural areas, peer review can be difficult due to the small number of physicians and potential conflicts of interest.

To solve this problem, RCHI developed a peer review system where different medical staff from rural hospitals could confidentially review each other’s records, improving the quality of care in rural communities.

“RCHI identified a way to improve health care in a rural community, specifically from a quality perspective, and then created solutions specific to those communities that needed a solution,” Parsi said.

RCHI provides other services to rural health care, such as utilization management, policy analysis, education, research, consulting and data reporting. The institute helps rural hospitals with their data reporting needs at the state and federal level, which can be challenging for small hospitals with limited staff.

In 2018, RCHI received a federal grant from the Health Resources and Services Administration (HRSA) to help rural hospitals across the country that were at risk of closure. RCHI selects 30 hospitals every year and provides them with resources and expertise.

“With a tiered approach, we identify the hospitals that have the most need and then provide resources for all aspects of a hospital operation, from strategy and development to billing and coding,” Parsi said. “This work has laid the foundation for increasing our capacity to support rural hospitals in Texas through a new state-funded rural health initiative.”

The future of rural health

RCHI, along with the Texas A&M School of Medicine and the School of Nursing, recently received state funding to expand its programs to support rural health care in Texas. The funding is part of an exceptional item request that aims to create a coordinated effort between the three organizations to improve rural health outcomes.

“One of the programs that will be expanded is student training. Medical and nursing students will be encouraged to do rotations in rural communities and experience what it would be like to be a rural health care provider,” Parsi said.

The programs that will be expanded also include workforce development, K-12 pathway education, alternative care models and telemedicine. The programs are designed to address the needs and challenges of rural health care, such as limited resources, a smaller workforce and financial viability.

“Only when you have significant challenges can you have wonderful success. Rural health care is challenging, but there are opportunities for us to make a significant difference in improving the health care of rural Texas,” Parsi said.

Benjamin LaCount contributed to this story.