Shortage of Health Care Workforce Hits Rural America Hard

Rural America faces a critical shortage of primary care providers, jeopardizing the nation’s ability to meet the health care needs of the rural population. Primary care providers offer routine care, health promotion and disease prevention, and treat chronic conditions – all fundamental needs of the rural population.

The primary care workforce is composed of physicians, nurse practitioners, physician assistants and certified nurse midwives. Registered nurses also play an important role. Shortages exist in all areas of this workforce; none of the providers can adequately care for the rural population alone.

According to the U.S. Department of Health and Human Services, over 20 percent of the U.S. population lives in rural areas, yet they are served by only nine percent of the nation’s physicians. This discrepancy is expected to increase as fewer medical students choose primary care and fewer still are tied to or appreciate rural life.

The decline in general practitioners means that physicians alone cannot meet the demands of caring for the rural population. Nurse practitioners are excellent choices to provide patient-centered primary care and can help fill the health care void in rural areas. Nurse practitioners are licensed to provide primary care for patients within their scope of practice, referring patients they cannot manage to a physician. They are well prepared to educate patients and families and coordinate care for complex patients.

Rural residents require care for chronic conditions such as diabetes and heart disease in greater numbers per capita than urban residents. Successful management of chronic conditions includes prevention of illness and ongoing health promotion. It also requires effective patient and family education in areas such as nutrition, exercise, medication management and emotional support.

Nurse education focuses on the care of the person in the context of their environment, and places a high priority on wellness and health maintenance. Nurses have traditionally served as patient educators and advocates. These roles are central to safe, effective primary care and serve as a natural bridge for increased rural practice.

A health care delivery model that supports this type of care is the health care home. The Institute of Medicine defines a health care home as a place where patients can receive integrated “health care services by clinicians who are accountable for addressing a large majority of health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

As the Institute of Medicine points out, the clinician role should not be limited to physicians. It can be filled by physicians, nurse practitioners, physician assistants, or other practitioners with the scientific knowledge and authority to direct the delivery of health care to patients. The National Rural Health Association also supports the development of health care homes.

Health care homes can improve the continuity of care for rural residents by serving as the central hub of a person’s health care services and records. In the current system rural residents travel to distant communities to receive care from many different specialists, frequently leading to fragmented and inefficient care related to poor communication and compartmentalized treatment. Health care homes in rural communities would not eliminate the need for residents to travel to see specialists, but would serve as a home base for the patients, allowing them to return to their health care home with their complete health record for follow-up care.

While it is clear that the supply of rural primary care providers of all classifications needs to be increased, it is equally essential that health care reform creates a framework for innovative ways to meet the health care needs of rural residents. Nurse practitioner-led primary care, including health care homes is one option. Another is built from the health care home model described by the Institute of Medicine to develop telehealth care homes in rural and remote areas. Incorporating these care delivery methods into health care reform can positively impact the availability of primary health care in rural areas and potentially improve the health of rural residents.

An encouraging bill in the U.S. Senate that seeks to increase the supply of rural health care professionals – including nurses and nurse practitioners – is S. 790, the “Health Access and Health Professionals Supply Act of 2009.” The bill employs a variety of measures to provide opportunities and incentives for health care practice in rural areas. As Congress develops health care reform legislation, they should include such provisions for the benefit of rural people and rural communities.

Written by Melissa Florell, a Center for Rural Affairs intern and a registered nurse who farms with her husband near Kearney, Nebraska. The full report, Rural Health Care Workforce: Opportunities to Improve Health Care Delivery, is available on

Get The Newsletter?