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Insights from BPC's Health Team Trip Across the Heartland

BPC’s health team traveled through America’s heartland to explore the health care landscape, finding both innovative programs in rural communities and significant challenges that Washington should address. Here are the team’s main takeaways on three important health care topics: mental health and substance use, rural hospitals, and digital and telehealth technologies

Our Trip

BPCs’ health team spent three days traveling to 20 locations across Minnesota, Nebraska, and South Dakota. Splitting into specialized groups, we explored rural hospitals, digital health initiatives, and behavioral health services.

Behavioral Health

BPC visited five locations that deliver crisis care to patients experiencing a mental health or substance use crisis. These services provide patients with a safe place to receive assessment, observation, and short-term treatment and give the community crisis options other than inpatient psychiatric care, emergency rooms, and incarceration. BPC also met with two school-based programs that cover a range of prevention, early detection, and treatment services for youth experiencing mental health and substance use risks and issues. Staff from Sen. Tina Smith’s (D-MN) office joined BPC for several site visits. Sen Smith serves on BPC’s Youth Mental Health and Substance Use Task Force Honorary Congressional Working Group.

Rural Hospitals

BPC met with a variety of hospitals, one of which recently switched to a Rural Emergency Hospital (REH) designation and others who considered REH but chose against it. REH is a hospital that provides emergency care and outpatient services but can no longer support inpatient services due to small volumes or costs. In addition, we met with two Sole Community Hospitals to discuss ongoing challenges with payment structures, transferring patients, and workforce issues. A Sole Community Hospital is a designation given to hospitals that are the primary source of inpatient care for a large geographic area, typically rural or underserved regions.


BPC’s digital health team toured multiple facilities to see how rural hospitals are connecting patients to care through high-quality virtual services. The facilities included two tele-emergency departments that connected patients directly with providers in other parts of the state to triage patients as they needed care. We also met with the team running a Project ECHO based in Sioux Falls to learn how the project creates educational hubs to train providers in rural communities and increase health care access.

What’s Working

1. Rural Resilience

At the forefront was the resilience of rural hospitals, operating at maximum capacity while striving to meet the diverse health care needs of their communities. The team received direct accounts about the pivotal role of designations like Critical Access Hospital and the emergence of the Rural Emergency Hospital model, providing a lifeline for struggling institutions.

2. Innovative Collaborations

Amid the challenges, innovative collaborations have emerged. Rural hospitals have forged partnerships with neighboring facilities and virtual care providers, extending their reach and enhancing service capabilities. Whenever possible, hospitals are successfully partnering with other providers to ensure smooth transitions from hospitals to other types of more appropriate care, particularly for individuals in mental health crisis. Multisector partnerships and school-based programs were crucial for addressing behavioral health needs and bridging gaps between health care systems and community resources.

3. Utilization of Technologies

Coming out of the pandemic and the rise of telemedicine, providers and health systems are utilizing new technologies to connect patients to care with providers outside of their region. Rural hospitals are partnering well with virtual care providers to extend access to high-quality services and enhance their own ER, ICU, ambulance, and other capabilities.

 Challenges to Address

1. Financing

The Rural Emergency Hospital model is the first new Medicare rural provider type in over 25 years, yet providers are hesitant to adopt REH without more guidance and adjustments to the current financing model. We heard from hospital leaders on that ground that they wanted to wait and see how other REH hospitals fared before attempting to convert.

2. Emergency Medical Services

Due to a fragile EMS and first responder system, some patients do not receive timely 9-1-1 responses or are not medically transported to other facilities in a timely fashion. Without clear, sustainable funding sources for EMS, emergency transport services will continue to struggle and create a disjointed system. One hospital executive told us “This is a five-year problem. If we don’t do things to address this now, we will be in real trouble five years down the line.”

3. Workforce and Health Care Services

Like many parts of the country, rural America needs more doctors and nurses; rural hospitals continue to have low financial margins (making it hard for them to maintain or expand services); and many mental health facilities and digital health services do not have sustainable financing mechanisms. Some hospitals are boarding patients for extended periods because the treatment facilities these patients need after their hospital care, such as nursing homes and behavioral health settings, are often filled to capacity.

What’s Next for BPC

What we learned will shape the policy options we present to our Youth Mental Health and Substance Use Task Force, especially around redesigning the health care delivery system. It also will shape our work on how to best use technology to extend the reach and capacity of the rural health care workforce.

In addition, BPC will be releasing a new report in September on how to improve the REH model to attract more rural hospitals that are struggling to keep their doors open. This report will build on our 2022 report, The Impact of COVID-19 on the Rural Health Care Landscape, ahead of the start of the new REH model. The 2022 report addressed many of the expected challenges with the REH model and explored ways that Congress and CMS could tweak the model should these problems arise. Additionally, we will release another report in early 2025 addressing possible improvements to the other Medicare rural hospital designations.

Our digital health team will release telehealth recommendations this summer. BPC will continue evaluating how innovative technologies like tele-emergency and tele-EMS can alleviate provider burnout and support rural workforce development.

BPC thanks the Helmsley Charitable Trust for its close partnership, which helps make this work possible.

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