As hospitals brace for a potential uptick in COVID-19 cases with the state reopening, small Missouri communities are facing problems exacerbated by the rural health care crisis that was already taking place in the U.S.

Since 2014, 10 rural hospitals in Missouri have closed, and more are expected to shut down, according to Dave Dillon, a spokesperson for the Missouri Hospital Association.

Mary Stanfield holds her dog, Casper, during a virtual visit with Sarah Kirchhoff. As a precaution, Western Missouri Family Healthcare has turned to virtual visits, which hasn’t been a simple process. “We have a little bit of an older population. So trying to teach them how to be able to use a virtual software like that has been a little bit challenging,” Kirchhoff said. “At the same time, since our patients know us really well, they can always call us.” Claire Hassler/Missourian

People living in remote parts of the state with severe COVID-19 symptoms must sometimes travel up to an hour from their town to access a hospital with ventilators.

There have been a few spikes of COVID-19 in rural areas, mainly around meat packing plants or on the outskirts of urban areas, but there is concern that things could get worse as the state reopens.

“We could very easily see this become a rural challenge as much as it has been an urban one,” Dillon said.

Rural hospitals and clinics are already experiencing financial hardships, along with a lack of resources and staff.

“There’s just a whole set of challenges that are being faced all in a very short window of time,” Dillon said. “There is a responsibility to do everything you can to maintain capacity to provide care.”

Financial roadblocks

Dillon said there were funding problems long before COVID-19. He said most hospitals work on about a 2% positive margin, meaning they barely break even.

“The biggest challenge is financial at this point,” Dillon said.

Dillon said hospitals statewide have been losing more than an estimated $32 million a day cumulatively because of COVID-19. Rural hospitals have lost about half their business, mainly because they had to cut elective procedures.

Sarah Kirchhoff presses her stethoscope into Jana Mueller’s back to listen to her lungs during a routine physical April 28 at Western Missouri Family Healthcare in Concordia. Since the state shut down, Kirchhoff has been seeing six to eight patients a day in-person, virtually or over the phone. Before COVID-19, Kirchhoff said she saw 12 to 15 patients a day. Despite these slower days, Kirchhoff said she has support from the entire community. Claire Hassler/Missourian

The Provider Relief Fund, which is part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, is providing $100 billion to hospitals and clinics all over the country; $30 billion has already been given out in general allocations, and $20 billion more of general allocations is being distributed in weekly installments. On May 1, $10 billion began being dispersed specifically to rural hospitals and clinics, according to the Department of Health and Human Services.

The remaining $20 billion of general allocations is currently being distributed proportionally, based on providers’ 2018 net patient revenue, which is the total revenue they made from inpatient and outpatient services.

Medicaid reimburses at lower rates than other providers, which means providers who have a lot of patients on Medicaid will get less funding, according to Kaiser Health News. This is problematic for rural areas because 1 in 4 of their nonelderly patients are on Medicaid, according to the Kaiser Family Foundation.

Dillon said federal funds that hospitals have gotten so far have only been the equivalent of about 12 days worth of their losses related to COVID-19, like eliminating elective procedures.

“The problem is, just like any other business, when you lose 50% of your revenue, you have to make hard choices,” Dillon said. “Not enough business in a health care pandemic — it’s hard to believe.”

Randy Tobler, CEO and physician at Scotland County Hospital in Memphis, Missouri, said financial aid comes from so many different sources, whether through grants, government aid or Medicare advance payments, that it’s hard to navigate. The most confusing part is determining which money the hospital will eventually have to pay back and if it will be able to make those payments when they are due.

“The devil is in the details,” Tobler said.

Tobler said his hospital had about a 75% decrease in revenue in early March. In the last two weeks, it has seen a 50% decrease in revenue. The hospital’s financial struggle and limited resources have forced them to be resourceful.

Rural hospitals adapt

Tobler said his hospital can manage COVID-19 patients who can be treated similarly to patients hospitalized with pneumonia or influenza.

“We don’t plan on transferring them out just because they have COVID,” Tobler said.

From left, Ciaira Cain, a practical nurse, speaks with Sarah Kirchhoff after doing blood tests for a patient April 28 at Western Missouri Family Healthcare in Concordia. During appointments, the clinic staff wear masks, goggles and gloves. They try to schedule appointments so routine procedures are in the morning and sick patients come in the afternoon. Claire Hassler/Missourian

However, Tobler said Scotland County Hospital cannot ventilate a patient for an extended period of time because it only has two respiratory therapists. With its staff, it is able to ventilate a patient for 48 hours.

Any patient who needs ventilators for longer than that would require a transfer. Tobler’s hospital has transfer agreements with regional hospitals like Blessing Hospital in Quincy, Illinois, University Hospital in Columbia and Northeast Regional Medical Center in Kirksville.

“It was a tornado watch. Now it’s a warning,” Tobler said. “The winds are whipping up because we’ve got outpatients that are positive. It’s just a matter of time before we hospitalize someone or I deliver a baby from someone that has it. So we’re braced and ready.”

Tobler said the hospital must be especially vigilant now because the state’s reopening could lead to a surge.

In response to COVID-19, Ozarks Medical Center in West Plains built a new viral ICU that doubles its ICU capacity to 22 beds, according to Kim Wood, a hospital spokesperson.

Wood said the hospital converted a lab into a negative pressure viral ICU. The negative pressure prevents air flow from the ICU rooms into other parts of the hospital. The hospital also has critical care intensivists, infectious disease specialists and a pulmonologist on staff.

“We’ve been ready,” Wood said.

Ozarks Medical Center serves eight counties in southern Missouri, about a population of 40,000, with people traveling as far as an hour away, according to Wood.

From left, Sarah Kirchhoff, Kim Harrington, Jacki Addington and Ciaira Cain laugh about an online video April 28 at Western Missouri Family Healthcare in Concordia. Addington said most clinics don’t have as much fun as theirs does. Later in the day, Kirchhoff treated her staff to smoked meatloaf from Dempsey’s BBQ, one of Concordia’s local restaurants. Claire Hassler/Missourian

About 200 miles away, in southeast Missouri, Southeast Health has also been preparing. Its facilities in Cape Girardeau and Dexter have ventilators and equipment to manage 75 COVID-19 patients.

It also has 51 satellite locations within its health system, and all of those are prescreening people before they enter the facilities. Shauna Hoffman, vice president of marketing and communication at Southeast Health, said everyone at the hospitals is doing everything they can to prevent further spread of the virus.

The Mercy health system has locations all over the state, each with a few beds for COVID-19 patients, but it has a plan in place to transfer severe patients to its Springfield hospital. According to Mercy spokesperson Sonya Kullmann, this is “a usual practice with many conditions.”

Its Springfield hospital has a capacity of 250 negative pressure rooms. If an unexpected surge happens, Kullmann said the hospital will use other Mercy facilities in Joplin, northwest Arkansas and the St. Louis metro area.

Sarah Kirchhoff dictates notes into her phone after a routine physical with a patient Tuesday at the Western Missouri Family Healthcare clinic in Concordia. Normally, Kirchhoff brings her laptop into the patient’s room and types her notes directly into their chart. In an effort to minimize exposing people to extra surfaces, she has resorted to writing notes on a notepad while in the appointment and adding them to the chart later. Claire Hassler/Missourian

Staff shortages

All of these plans require staff to execute them, but staffing rural hospitals has proved to be another issue that worsened by COVID-19.

“Fifty percent of hospital operational costs is your staff,” Dillon said. “If you lose your staff, they may not come back. And if they don’t come back, well, then you’ve got a building, but you don’t have the ability to provide services.”

Large hospitals across the state, including MU Health Care, are addressing staffing issues. Tobler has noticed this, too.

Sarah Kirchhoff dictates notes into her phone after a routine physical with a patient April 28 at Western Missouri Family Healthcare in Concordia. Normally, Kirchhoff brings her laptop into the patient’s room and types her notes directly into their chart. In an effort to minimize exposing people to extra surfaces, she has resorted to writing notes on a notepad during the appointment and adding them to the chart later. Claire Hassler/Missourian

Tobler said staff sharing among other health systems might be a possible solution, but that is in the early discussion stage. Scotland County Hospital used to employ 140 people full time and 30 people part time as needed. Now, it employs 125 people full time and 25 people part time as needed. It had to cut staff because of the hospital’s loss of revenue in the last month from COVID-19. Tobler is concerned about meeting the needs of the community.

“There’s a real possibility, depending on the amount of the surge, that that diverts enough of our staff because of the intensity of care they need, that we won’t have the staff to take care of regular patients,” Tobler said. “It’s a minute-by-minute, day-by-day thing.”

One thing that may help rural areas is advanced practice registered nurses being allowed to give care without a physician present.

The Missouri Department of Health & Senior Services waived regulations to allow nurse practitioners to practice without a physician in early April. Dillon said this benefits rural areas.

Lights are dim in the waiting room Tuesday at the Western Missouri Family Healthcare clinic in Concordia. To minimize person-to-person contact, the clinic has moved most of its appointments to virtual visits and has a sign posted on the door instructing people to call the clinic before coming inside the building. Of course, not all in-person visits can be avoided. “Patients still have high blood pressure and patients still have diabetes, even with all of this going on, so we’re really trying to make sure that we're not letting their chronic conditions fall through the cracks,” Kirchhoff said. Claire Hassler/Missourian

“That’s often what rural health care looks like in communities that don’t have a hospital. So the more that they can practice to the full extent of their training and licensure, the more people that we have in rural communities that can provide those kind of services,” Dillon said. “In some communities, you couldn’t recruit a doctor to live in the smallest of communities, but you could have a nurse practitioner in a clinic.”

Sarah Kirchhoff is one doctor who does work in a small rural community. Kirchhoff works at Western Missouri Family Healthcare in Concordia, where she grew up.

When it comes to being a family physician in a rural area during the COVID-19 pandemic, Kirchhoff said there are pros and cons. Isolation from urban areas with more cases limits exposure, but lack of access to care if there were a surge in Concordia increases risk.

Isolation no longer a benefit

If Kirchhoff’s patients need to be hospitalized for COVID-19, she said she will send them to the clinic’s associated hospital in Warrensburg, about a 30-minute drive from Concordia. This could be problematic because some of her patients have issues getting around.

“For some of our patients, they can’t get much more than 10 minutes out of town ... without a lot of difficulty,” Kirchhoff said. “Just even trying to get them to the hospital can sometimes be a barrier.”

The town of Concordia, as seen through the peephole on the back door of Western Missouri Family Healthcare. The clinic is located on Concordia’s Main Street and is a two-minute drive from Sarah Kirchhoff’s home. Claire Hassler/Missourian

If Warrensburg reaches capacity, Kirchhoff said Marshall and Lexington have the nearest hospitals, but those are also small facilities.

“We’re just physically distant from a lot of the resources,” Kirchhoff said.

Scotland County Hospital is in a similar situation. It serves four counties in northeast Missouri and two in southeast Iowa. The nearest hospitals are Van Buren County Hospital in Keosauqua, Iowa, and Davis County Hospital in Bloomfield, Iowa, both about 40 minutes away.

“All it takes is, you surge up to 14 or 15 regular patients, and you add another four or five isolation patients, that’s going to be overwhelming for our staff and our resources. That’s the reality,” Tobler said.

Despite the distance and lack of immediate resources, Kirchhoff said she feels prepared.

“I know that Warrensburg has a plan in place for any sort of a surge that happens,” Kirchhoff said, “and I know they’ll do the best they can with the resources they have.”

Sarah Kirchhoff smiles at her husband, Ryan, as he prepares to take their son, Aiden, 3 months, to Ryan’s parents’ house before going to work April 28. Kirchhoff grew up in Concordia and returned to practice medicine. Claire Hassler/Missourian