During normal times, the nurses at Family First Health Care in Adair County handle 6,000 visits a year for everything from preventative care to chronic treatment for diabetes and heart disease to farm injuries.

But these are not normal times.

Many of the services rural health clinics like Family First provide have been put on hold. That helps with social distancing and preserves medical capacity for a potential surge in COVID-19 patients, but it also means fewer patients coming through the door and paying for health care.

At a time when they are needed perhaps more than ever, clinics like Family First are worried about making ends meet.

“It’s pretty scary for anybody, myself or my staff, to get sick,” said nurse practitioner Beth Partin, who runs the clinic with her daughter. “And then it’s scarier as a business owner as to what’s going to happen to my practice. And what’s going to happen to my patients?”

There are only four primary care options for the over 19,000 people living in Adair County: a small hospital, Family First Health Care in Columbia and two other small clinics. The first case of coronavirus in Adair County was confirmed at the T.J. Health Columbia hospital on March 31. Partin says her clinic is treating every person who walks in the door like a potential case.

“We’ve asked folks to try not to fill up the waiting room,” said Jill York, Executive Director at Kentucky Coalition of Nurse Practitioners and Nurse Midwives. “At the same time, they need to be able to keep the lights on — and care for the folks who do truly need their services right now. It’s kind of hard to ask them to do both.”

Medically Underserved Regions

Even if the coronavirus never penetrates rural Kentucky with the caseloads seen in more urban areas, the financial strain of the outbreak threatens an already vulnerable rural health system.

Michael Topchik is the national leader for the Chartis Center for Rural Health, a research and consulting firm. Topchik says clinics work in tandem with hospitals to provide care in rural areas.

Topchik describes hospitals as the hub of the rural healthcare system. They treat emergencies and provide specialty services such as surgeries.

“Clinics are the front line,” Topchik says. Their job is to keep people healthy and out of the hospital through routine checkups and regular treatment for chronic conditions such as diabetes and heart disease that are more common in rural areas.

The Chartis Center for Rural Health has produced research that shows how vulnerable rural hospitals are to the coronavirus. Much like clinics, rural hospitals rely on outpatient services for revenue, these are the same kinds of services that hospitals have been ordered to stop performing for the duration of the outbreak.

That, coupled with the fact that the average rural hospital only holds enough cash reserves to operate for 33 days according to Chartis Center research, could spell financial ruin for many facilities. Topchik estimates we could see 200 to 400 rural hospitals close nationwide without immediate relief.

That would put more pressure on the 251 health clinics in Kentucky working closely with hospitals to keep rural communities healthy — and they are already in a similar financial bind.

Senators Michael Bennet (D-Colo.) and John Barrasso (R-Wyo.) introduced legislation last week to provide financial relief for rural healthcare facilities in the form of one-time emergency grants. “Even before the outbreak, many of our rural hospitals and providers were on the brink of shuttering,” Bennet said in a press release. “Now they face an existential challenge.”

Topchik says that preserving the rural healthcare system during the outbreak is “a moral issue.”

“Are we going to make sure we have access to health care in rural areas, or are we going to let that go?”

Clinic’s Patient Visits Upended

The coronavirus has already upended how clinics in Kentucky treat patients.

Donna Isfort has owned the Estill Medical Clinic for about 12 years. She and her fellow nurse practitioner, Liz Taheny, have had to rethink their entire practice.

Isfort and Taheny will meet patients in the parking lot for prescreening, where they take temperatures and screen for coronavirus symptoms using an algorithm passed down from the Department of Public Health to determine who gets tested. They wear personal protective equipment all day, and are careful to ration supplies.

They screen each other for COVID-19 symptoms every day before work and keep a log of the staff’s temperatures. They change clothes at the clinic before leaving, careful not to take anything that could carry the virus into their homes.

Both nurse practitioners worked at UK Chandler Hospital before the rural clinic. Taheny calls it “a different kind of stress”: fewer acute emergencies, perhaps, but rural clinics also have fewer resources and smaller staffs. Then, there’s the added stress of caring for neighbors and other people from the community where Isfort has lived her entire life. Estill County is home to just two clinics and a 25-bed critical access hospital.

Isfort is worried about the financial impacts of their patients staying home. On Friday, the clinic saw 20 patients when they’d normally treat upwards of 50.

“I have 14 employees, and all of my employees have family. And their paycheck from here helps put food on the table and helps pay their bills,” Isfort said. The clinic has a few weeks of cushion, Isfort said. She says the clinic has stopped using part time staff and cut back on non-essential supplies to help stretch finances.

Isfort said they will start to run out of personal protective equipment around Easter if things continue at this pace. Their usual sources for personal protective equipment are either sold out or on back-order, but Isfort says the community has rallied around the clinic. The county health department has helped secure protective masks, patients have sewn masks and gowns and even delivered cake to the clinic parking lot.

They have so far sent only a handful of coronavirus tests off to private labs. The county doesn’t have many kits, Isfort said.

“So each one of those has been precious and we’ve tried to determine, if this is someone who actually meets the criteria, is this a necessary test?”

Partin in Adair County has sent out six tests as of April 1; all came back negative. She has waited as long as 5 days for results.

The wait for test results can be anxious. Partin’s is a small staff: just two nurse practitioners, a nursing assistant and two people working at the front office. If one of them is exposed and gets sick, they will have to shut down for at least two weeks.

That means patients with chronic conditions would have to find another healthcare provider in an area where options are already few. Partin said patients become like family, especially elderly patients accustomed to getting their healthcare from a familiar face.

“When you’ve been in practice for a long time, and patients know you, you’re the person that they want to see when they get sick,” Partin said. “And sometimes they will not see anyone else when they get sick.”

And like healthcare providers everywhere, they don’t have enough personal protective equipment to truly feel safe. Partin bought 10 N95 masks on Amazon for $40 — much more than they would typically cost. A neighbor donated 20 masks they got from Sherwin Williams. Then last week the Adair County Public Health Department distributed masks throughout the county. Partin’s clinic received 80 masks. But it’s still not enough.

“I don’t think we can get any help,” Partin said. “I think everybody is desperate.”

Contact Jared Bennett at jbennett@kycir.org.