Kelly McGrath, M.D., helped to launch a readmission prevention initiative at Clearwater Valley Hospital in 2010, unsettled by the "appalling" rate at which discharged patients were returning to the 23-bed Orofino, Idaho, facility.

The time-intensive, staff-driven effort worked: medication reconciliation improved, the visiting nurse serve was used more frequently and an effort was made to get every patient into a primary care clinician's office within seven days after discharge. The 30-day emergency room readmission rate, 34.5 percent in 2009, was averaging 12.2 percent by a post-intervention analysis March 2011 through January 2013.

"It's better care," says McGrath, the hospital's chief medical officer. But the physician also believes that refocusing and redeploying some staffers to provide more comprehensive support will help in the post-Affordable Care Act world. While hospital readmission penalties haven't yet applied to critical access hospitals, McGrath says it's just a matter of time before federal officials take that step. "They just haven't gotten there yet."

For rural hospitals already struggling with the perpetual headaches of recruiting, the ACA's rollout only raises the stakes and uncertainties, according to leaders and health policy experts. Amid a patchwork rollout of Medicaid expansion and a flawed launch of the federal exchanges web site, how can they possibly staff for the unknown? Plus, how should they position staffers moving forward, given that the health system is starting to shift away from fee-for-service reimbursement?

As of late 2013, rural hospital leaders seemed to be adopting a wary, wait-and-see stance until they have a better sense of which newly insured patients are coming through their doors, says Brock Slabach, a senior vice president at the National Rural Health Association. "Given the fact that there's the shortage of physicians and mid-levels in rural areas to begin with, any increase in volume will be an exacerbation to an already stressful situation," he says. "You could have patients that, because they haven't had insurance for a long time, or never, they are going to have a more complicated medical history."

Some rural facilities also might need more staffing to assist with billing and collections, as patients adjust to the new insurance coverage, Slabach says. Boosting clinical support staff, such as by adding a social worker with mental health expertise, might ease the strain of increased patient volume and improve patient care, says David Schmitz, M.D., program director of Rural Training Tracks for Family Medicine Residency of Idaho.

Any staffing scenarios, though, come with a financial catch, Schmitz says. "I think the challenge is that many times there are the right things to do for a patient population, but how do you support those services?" he says. "Many of our hospitals live with very, very thin margins and I think are under increased pressure to reduce all but the necessary staffing and services."

Staffing to Watch

At Iowa's Trinity Muscatine Hospital, CEO Jim Hayes reported in late 2013 that the 56-bed non-profit hospital had added four certified counselors, all bilingual, to assist Spanish-speaking residents with signing up on the health exchange. Otherwise, he described his mood as "antsy." "My fear is that now we're going to have this influx of patients," he says. "We're already working pretty much at capacity now."

On the good news side, former non-paying patients will be carrying insurance cards, he says. "The downside of that is that a lot of them will elect for the high-deductible plans," he says. "And, if their deductible is $2,000 to $5,000, they are not going to pay that."

Some patients may be stunned by the sometimes hefty deductibles involved with the lower premium plans, Slabach says. "I think boards should be very aware that the perception may be, with all of these newly insured, that we're not going to have bad debt or charity anymore," he says. "But that's not going to be the case."

Still, rural hospitals do enjoy some built-in advantages, as they've already been treating a lot of these patients anyway for years, so they might have a sense of who can take advantage of expanded coverage, says Terry McGeeney, M.D., a director at BDC Advisors, a health system strategy consulting firm.

"You do know the dynamics of the community and know everyone who comes in, and who has insurance and who doesn't," says McGeeney, who practiced in a Midwestern community of 2,300 people earlier in his career. "You just have a much better intelligence of what's going on in your community and I think they'll be able to react to that."

Redeploying Skills

To tackle their readmission rates, McGrath and his team didn't add staff positions, but redeployed some of the time they spent on certain tasks. For example, a medical assistant might now spend a chunk of each day focusing on medication reconciliation for patients prior to hospital discharge, he says.

Like other rural hospital leaders interviewed, McGrath is a bit edgy about the clinical uncertainties that 2014 brings. He's already taken his own primary care physician recruitment efforts up another notch. "I feel like I'm recruiting either rock stars or NBA players," he quips. "We are all competing for the same talented pool, so there's not going to be enough to go around."

But the readmission initiative continues, at an estimated hospital cost of nearly $150,000 annually that's more than counterbalanced by at least $660,000 in annual savings. But McGrath points out that the savings, so to speak, are reaped by Medicare — the at-risk patients targeted are age 65 or older — rather than helping Clearwater Valley to re-invest in additional staff and other clinical initiatives that might be beneficial in the years ahead.

For more on recruiting and retaining rural physicians, read the January cover story, "Done Recruiting? Start Retaining."

Charlotte Huff is a health and business writer in Fort Worth, Texas.