In 2018, a Pew Research Center study found that on average, rural Americans live 10.5 miles from the nearest hospital. An ongoing wave of small-town hospital closures keeps pushing those numbers up, with over 180 rural hospitals shut down over the last few decades.

The need for hospital care during the COVID-19 pandemic only brought this crisis to a head. About one in four rural households reported being unable to get care for serious problems during the pandemic, according to a nationwide survey.

Across New England, as in much of the country, there is also an acute shortage of doctors and nurses. Although nearly 20 percent of people in the United States live in counties designated as “rural” by the Census Bureau, only about 10 percent of the country’s doctors practice in those areas. That number is poised to decrease as up to a quarter of rural physicians are likely to retire over the next decade.

These factors have created a crisis of care in these areas. Today, many residents of rural towns live an hour away from the nearest doctor or emergency room, making high-quality medical care increasingly difficult to access.

A county where care can be hard to find

Cheshire County, N.H., is one of the most sparsely populated regions in New England. While the central town of Keene, N.H., boasts a bustling community of about 23,000 residents, most towns in the county have between 600 and 1,500 residents spread across miles of land. The Cheshire Medical Center is the primary source of care for this entire region, and it faces the stressors typical to rural communities across New England.

Shawn LaFrance, vice president for population health, Cheshire Medical Center

“We do a random telephone survey every two-and-a-half years of the population in our region,” says Shawn LaFrance, the vice president for population health at the Cheshire Medical Center in Keene. “It’s just been consistent that transportation is the first or second biggest access issue for people to get to health care.”

This problem is particularly true, he says, for the county’s elderly population, which continues to grow as residents age. Many can no longer safely drive themselves, especially to far-flung towns and on the back roads of Cheshire’s most rural communities.

Distance is one of what Cheshire Medical Center CEO Dr. Don Caruso calls the “huge barriers” of providing care to a rural community — another is finding enough doctors to cover the area.

“Our biggest challenges really fall toward having physician staff to take care of the population that’s really spread out. There just aren’t enough physicians across the country, and it’s even worse in a rural environment.”

— Cheshire Medical Center, CEO, Dr. Don Caruso 

Dr. Don Caruso, CEO, Cheshire Medical Center

Mental health care is another hurdle for Cheshire County and others like it. In these areas, psychiatrists and psychologists tend to be few and far between. Because of this, people in rural communities who are dealing with mental health issues are statistically more likely to see the inside of a jail cell than a doctor’s office.

Olivia Belanger, health reporter, Keene Sentinel

“Our county, and the entire state of New Hampshire, is in desperate need of mental health and substance abuse treatment centers,” says health reporter Olivia Belanger, who covers health care for the Keene Sentinel. While residents acknowledge the need, they are often hesitant to welcome these facilities into their communities. For example, in Keene, plans for a walk-in mental health care center were rejected by the city.

Looking outside the hospital

Addressing the problems in rural health care goes beyond individual clinics and providers.

As Ann Marie Day, executive director for the New England Rural Health Association, points out, the definition of “rural” New England covers territory from the forests of Maine to the Berkshires and even areas of Cape Cod. There’s no single solution for providing health care to such a wide range of areas — and populations. The rural health care solutions have to embrace this diversity to help communities address their specific needs.

For some health concerns and populations, the answer could lie in telehealth services.

Over the course of the COVID-19 pandemic, telehealth emerged as a strong alternative to a traditional doctor’s visit. Patients now use their devices to consult doctors on issues ranging from basic consultations all the way to the management of severe and chronic illnesses. By late 2020 nearly one-third of all doctor’s visits were conducted remotely. While experts anticipate that number will dip as COVID-19 abates, many want to continue using telehealth and there is enormous potential for rural towns. It could mean eliminating lengthy and often costly trips to the doctor’s office for rural patients — removing distance as one of the biggest challenges for rural providers.

However, communities need to invest in the infrastructure and the outreach necessary to make it work.

“Telehealth has been our county’s saving grace when it comes to reaching our residents [during COVID].”

— Olivia Belanger, health reporter, Keene Sentinel

Telehealth technology, Belanger says, will be most valuable to aging patients who struggle the most with traveling distances to see their doctors. Yet this is precisely the population that is least likely to have and understand the technology, and, as Belanger points out, people in rural areas often lack reliable internet access.

Improving the physical and social infrastructure necessary for telehealth will take significant investment. Communities will need to invest in broadband to ensure access to necessary devices, and help patients get comfortable with potentially unfamiliar technology. But it promises to help close the gap between patient and doctor in a world where the nearest hospitals are far and getting farther away.

As traditional rural health care infrastructure continues to face threats, creative solutions like these are providing hope for New Englanders.

Updated November 2022:

Point32Health health plans Harvard Pilgrim Health Care and Tufts Health Plan are the first in New England and among the first nationally to achieve full NCQA Health Equity Accreditation. Learn more about our commitment to reducing disparities and improving care so all we serve can reach their full health potential: read the press release.