After a Rural Hospital Closed, a Health Center Fills Gaps in Patient Care

Providers at Lone Star Family Health Center have seen an influx of young patients following the closure of a rural hospital that also offered primary care in Trinity, Texas. Most of the patients live in rural communities with few or no options for family or pediatric care.

Trinity’s hospital closed after operating for just 14 months due to financial constraints in the small southeastern Texas community. According to the Texas Tribune, it was the second time the rural hospital was opened and shuttered. The hospital closure had an impact on primary care in the area as well, after a local primary care physician who also accepted Medicaid patients, stopped practicing. The closure has forced patients to seek emergency and primary health care farther away, but their options are limited as more than a third of the town’s population is living in poverty.

What has happened in Trinity reflects a broader, national issue: a lack of access to quality, affordable health providers in rural areas. As hospitals close, patients are being asked to travel long distances for care. After the closure in Trinity, the next nearest hospitals – Mid Coast Medical Center in Crockett, Texas, and Huntsville Memorial Hospital in Huntsville, Texas – are each 30 miles away.  

Analysis from Direct Relief’s Data, Metrics, and Impact team found that Texas’s rural populations are at a high risk of hospital closures.

Using data gathered from the University of North Carolina and census information, Direct Relief identified state vulnerability to hospital closures through rural population and the number of already at-risk hospitals. New York, Texas, Illinois, California, and Florida have the greatest number of rural populations at-risk of losing rural hospitals. The UNC research documents the closure of 110 rural hospitals across the United States since 2005. Twenty of those were in Texas. Within the same time frame, 85 rural hospitals were converted into outpatient and primary care clinics or urgent care centers; five are in Texas.  

States that expanded access to Medicaid are most at-risk of federal funding cuts that could impact hospital closures. Texas has never expanded access to Medicaid; however, recent legislation changes are expected to narrow access to the government-funded program even more, including education programs and infrastructure.

While Trinity residents, enrolled in Medicaid or otherwise, have driven 20 minutes south or more to seek primary care services at Lone Star’s Huntsville location, the health center, and others like it, will see their own cost constraints as they continue to take on more patients from farther away.

A Hub for Patient Care

Each year, Lone Star Family Health Center serves over 30,000 patients across five locations in southeastern Texas.

“Huntsville’s location is interesting because it catches a really wide patient (population),” said Karen Harwell, the health center’s CEO.

Huntsville’s population is nearly 48,000 people and most households earn less than $50,000 annually. The health center expanded into the small town during the Covid-19 pandemic as the city is surrounded by medically underserved areas, like Trinity, mentioned earlier, whose population sits at 2,258 people, and the median household income is less than $28,000 annually.

Finding a qualified provider in a small or rural community can be a challenge. Keeping them in the area is an added difficulty.

“We’ve struggled ourselves with keeping a full workforce, particularly in our more rural site,” Harwell said.  

Lone Star’s Huntsville location lost two providers within the last three years. The location sits within a Health Professional Shortage Area by HRSA, or an area where there is a shortage of primary care, dental, and mental health providers. When news broke of the Trinity hospital closure, Lone Star expected an influx of patients and hired a third provider to support behavioral health needs.  

Harwell said she would hire at least eight providers if she had the space and resources. Like many health centers, Lone Star’s Huntsville location struggles to meet the high cost of patients’ dental and obstetric care needs.

“The access is shrinking,” she said.

How “Growing Your Own” May Help Rural Areas

However, since Lone Star Family Health Center was founded through a residency training program and is within a Health Professional Shortage Area boundary, it can recruit and gain federal funding through the National Health Service Corps and the Teaching Health Center Graduate Education Program. Both programs incentivize providers through stipends and help them pay back student loans.

Dr. Lata Joshi is the chief medical officer of Lone Star and, for the last 10 years, has served as the Family Medicine Residency Program Director based in Conroe, Texas.

Lone Star has 36 residents currently enrolled in the program. Some have come from small towns and are following the medically underserved track to learn how to engage patients within specific populations. Dr. Joshi said she suspects some of the residents will return to their small towns upon completion of the program.

Growing that qualified workforce takes a lot of time, effort, and resources, said Brock Slabach, chief operations officer at the National Rural Health Association. He said that’s why “grow your own” programs, or education programs that encourage students from a young age to become interested in the medical field, can be helpful to rural health providers.

Through ongoing education, workforce training, and student loan support, many hope that students will return to small towns where they already have a personal connection to provide care.

“I lived in a lovely community in southwest Mississippi that I thought was great. I thought to myself, ‘I don’t understand why anybody wouldn’t want to live here’,” Slabach, a former hospital administrator, said. “But when you bring people from the outside, they don’t always see it that way.”

Slabach acknowledged that providers in rural areas are often asked to do more. Patients expect a continuum of care and are often asked to solve unique challenges. They’re also less likely to make referrals, since there are few doctors in the area, and to avoid forcing patients to travel even farther away.

Slabach suggested that using data from community health needs assessments could yield creative solutions and mitigate provider burnout.  

“We’re all incredibly challenged, not just in healthcare, but across many industries, to do more with less,” he said. “There’s an exhaustion that comes along with that. You have providers that are burning out because they don’t have more to give than they already do.”

Lone Star continues to innovate, including with the creation of community pharmacies in rural areas to support patient needs while mitigating home visit costs. However, Harwell, who has worked at the health center for 14 years, said they have felt the financial strain over the last two years more than ever before.  

“Sites try to recruit and retain a qualified workforce, add services to meet patient needs, and just continue to change and evolve,” she said. “The mathematical equation is getting harder and harder.”

Transportation: A (Big) Piece of the Puzzle

Beyond a qualified workforce, Lone Star providers say that transportation is the biggest barrier for patients trying to access care in rural communities.

“In rural communities, there is a longer commute, and when patients come, it’s more complex,” said Dr. Joshi. “They want a lot of stuff to be addressed at the same time, especially the older population. And they do it when care is really needed.”

With the hospital closure, patients have to travel farther for care. Dr. Joshi said that patients who have unreliable or inconsistent transportation may seek care less often.

She said it’s a ‘complex situation’ as rural care evolves into underserved care.

“Underserved care is a little bit different because it requires more social determinants of health that need to be addressed,” said Dr. Joshi. “It’s not only transportation. If you have a transportation issue, you have a transportation issue and a getting to the grocery store issue.”

Slabach called transportation issues within rural communities an ‘increased complexity’ – especially for patients on specific treatment plans. He questioned whether AI tools or other mechanisms could be used to better support patients from a distance.

“I’m hopeful that the (federal) Rural Health Transformation Program can help with a number of social determinants of health through programming for chronic disease management and (by) organizing case managers and community health workers,” he said.

Areas considered rural also change over time. When the health center opened the Conroe location, it was considered a rural area. Residential and commercial developments over the years have shifted the city into a suburb of Houston. Lower-income residents who originally lived in the once-rural area were pushed out farther north. Harwell said she anticipates more of this in the future.

“You go from what feels like a very urban area with a lot of wealth, a lot of commercial property, retail, and then you quickly get to where there’s no running water, a Title One school, and no electricity,” Harwell said. “In Trinity, they’re hanging their clothes on the lawn to dry.”

Half of Trinity’s children and 31% of its seniors are living in poverty, according to Census data.

“It’s affordability,” Harwell said. “Transportation’s huge. The further rural you get, there are definitely no transportation options, no public transportation options,” she said. “Overall, we see a lot of folks due to social determinants of health, the non-medical drivers of health, regardless of location.”

Direct Relief is committed to providing medical aid and support to health centers across the United States, including those in rural areas. Since 2008, Direct Relief has supported Lone Star Family Health Centers with more than $1.2 million worth of medical aid. The organization also received $237,000 in financial support from Direct Relief to support patient care.