In the early twenty-first century, the phenomenon of rural hospital closures has deeply affected millions of Southerners who do not live in or near large cities or towns. The closures have caused many rural Southerners to rely on unconventional methods of obtaining medical care, whether due to poverty, lack of transportation, or a misunderstanding of the healthcare system, any of which can affect a person’s beliefs. In this essay, a nurse who has worked in these settings shares her experiences and discusses the narratives that go along with people’s unmet needs.
Where Will They Go?
Rural Hospital Emergency Rooms in Rural South Carolina
by Janet Lynne Douglass
In the state of South Carolina, there are approximately ninety healthcare facilities, including fourteensmall county rural hospitals, which have been called the cornerstone of the healthcare system by the state’sOffice of Rural Health. Many of these small rural hospitals have struggled to stay open as decreased funding has impacted viability. Five of them have closed. As of 2021, these rural hospital closings include Fairfield Memorial Hospital in Winnsboro, Crawley Memorial Hospital in Boiling Springs, Southern Palmetto Memorial Hospital in Barnwell, Bamberg County Memorial Hospital in Bamberg, and Marlboro Park Memorial Hospital in Bennettsville. A main indicator linked with decreased funding and vulnerability is thought to be the political decision of South Carolina’s state government to not expand Medicaid under the Affordable Care Act, which could have facilitated improved hospital financial performance and significantly reduced the probability of hospital closure.
The five rural hospitals that closed were equipped with an emergency room (ER) and frequented by rural people seeking primary care. There are reasons why these rural ERs were frequented by the local population for primary care, and research has shown the patterns to be lack of access to other health care options, hardships with transportation, and older, impoverished and more vulnerable people are found in rural areas. According to the white paper “The Essential Role of the Urgent Care Center in Population Health,” authored by the Urgent Care Industry and published in 2017, rural ERs in the United States serve 17% of all patient visits.
Rural Healthcare Experiences
In the late 1970s, as a registered nurse, I worked in the rural hospital ER in my hometown of Winnsboro. Patterns quickly emerged as families and individuals frequented the now-closed Fairfield Memorial Hospital ER for chronic problems and non-emergent episodic care. Lack of transportation to primary care offices during workday hours, inability to pay for primary care in offices due to being uninsured, and the convenience of 24-hour access to care emerged as patterns.
An interview with a seasoned registered nurse colleague who spent many years working as an ER nurse, and later many years in rural home care, shared the patterns emerging from her personal experiences regarding ER use for primary care and her home care experiences. She told me in our interview, “I know why the patients return again and again to the ER. When working in home care I was sent to evaluate many of the patients that frequented the ER on a regular basis. One example was a man with renal issues. He was supposed to be on a special diet, and when I went to see him in his home, a small, old and worn camping trailer, I discovered he had no electricity and no running water. He was cooking over a campfire outside, heating beans from a can. He had no money for his medications or healthy foods. Each time that his illness caused severe symptoms he returned to the ER, was treated aggressively, sometimes hospitalized, and then sent back home to the same conditions. How was he to get better? The medical professionals had no idea of his personal situation”
From 2002 through 2005, working as a nurse practitioner in several rural ER settings in South Carolina, two patterns were evident in my ER experiences: the ER was convenient access to care for working families, and the uninsured were able to access care without being turned away. For example, when working at Clarendon Memorial ER in Manning, when patients were asked at check-in, “Who is your primary care provider?” my name was often given. I was the consistent PCP for these patients in their world view. The ER check-in staff attempted to correct the patients by stating that I was an ER Practitioner, not their PCP, but the pattern remained regardless of attempts to educate patients. I treated babies, young children, young adults, parents, and grandparents— whole family units. I built relationships with these patients, and they learned to trust me.
One example was a Hispanic family of migrant farm workers, who worked on a rural farm about a mile from the local Clarendon County Hospital. The family of five became familiar faces and frequented the ER with health concerns such as coughs, upper and lower respiratory illnesses, fever, insect bites, and headaches. I was always named as their PCP. They were confident that they could communicate with me since I could speak Spanish, and I felt that this was a contributing factor to their ER use.
I found the same patterns at Carolina Pines Medical Center ER in Hartsville, where I also worked during this same time period. Even though this was a regional medical center, I found ER use for non-emergencies present here, too. A particular patient with hypertension asked me upon discharge, “When do you work here next month so I can come see you again for my pills?” When it was suggested that he see a PCP, he said, “I work odd hours seven days a week. It is easier to come here.” This patient was uninsured.
Later, working in a rural NP-managed family practice setting from 2008 through 2020, I received ER reports frequently for my patients. Attempts were made by staff, including me, during the office visits to educate them about seeking care in the office before going to the ER. Comments were “I didn’t have the money to come here,” “I have a bill here,” “I have to pay someone to bring me here,” and “your office was closed,” reflecting the patterns of access and inability to pay.
In 2018, the rural hospital in my hometown of Winnsboro, no longer viable, closed the doors, and this local rural hospital ER was no longer an option for care, emergency or otherwise. However, a free-standing ER owned by a private company was constructed and advertised as the emergency option.
The word emergency may mean something different to rural individuals who have always gone to the ER for care, learned behavior passed on in families that do not seek preventive/primary care, or cannot travel to office visits. Some patients state they have been turned away from the private. Where will these patients go now?
Hope for the Future of Rural Health Care
My current practice is a part of a Federally Qualified Health Care Center (FQHC). We provide care to the insured, underinsured, and uninsured. FQHCs offer another option for access to care for rural and underserved areas and populations. Extended hours, affordable services, diversity of health care providers/specialists, have all assisted with bringing the care back into the office and away from the ERs. Most rural counties in South Carolina have an FQHC.
If there is no local ER, patients have the option of accessing care at a FQHC for quality and affordable care. They have somewhere to go. Health care providers in the ERs, medical offices, and otherwise, need to spread the word about FQHCs and educate, especially in rural areas and areas that have no hospital, that the FQHCs are a quality option for primary care. At the local ER, the sign on the closed door should have the address and phone number of the nearest FQHC so that those that have used the local ERs over the years for primary care will know where to go for help.
Janet Lynne Douglass is a Family Nurse Practitioner in South Carolina. She received her undergraduate and Master of Nursing degrees from the University of South Carolina, and her Doctor of Nursing Practice from The George Washington University in Washington D.C. She has published works in the Narrative Inquiry in Bioethics: A Journal of Qualitative Research: “Challenges with Healthcare in the Rural and Prairie Environment,” “A Nurses Personal Story” Volume 9, Number 2 (Summer 2019), and also in the Journal of Theory Construction and Testing “Using Peplau’s Theory to Examine the Psychosocial Factors Associated with HIV-infected Women’s Difficulty in Taking Their Medications” (2003).
*Sources available on request.