A Guide to Telehealth in Rural Communities

Far from city lights and suburban sprawl, rural communities across the United States continue to face public health challenges. According to the National Institutes of Health, rural Americans are more likely to die early from cancer, lung disease, heart disease and stroke than those in other areas. The health challenges in rural America also include higher rates of diabetes and obesity and greater risk of suicide, fatal car crashes and overdoses.

With 46 million people living in rural areas, making up about 15 percent of the U.S. population, the American Medical Association reports that the growth of telehealth in rural communities is providing a much needed option to patients in these areas who cannot visit a doctor’s office. The availability of telehealth services can help improve the health of people in small towns and farming and ranching communities across the country.

What Is Telehealth?

Providing health care via telehealth in rural communities allows patients and physicians, practitioners and other health care professionals to communicate remotely through telecommunications equipment. To deliver health care services remotely, health care providers use technology, primarily two-way, real-time interactive communication methods, that includes:

• Real-time audio, video or phone visits, guided by state rules
• Email, text and instant messaging
• Remote devices that transmit health data for ongoing monitoring

Expanding on the definition of telehealth requires understanding the related term telemedicine. While in the context of Medicaid’s definition, telehealth used to be referred to as telemedicine, there are key differences between the two: 

• Telemedicine specifically refers to remote clinical care provided by health care professionals such as physicians and nurse practitioners. Clinical care can include diagnosis, treatment, follow-up care and facilitating access to specialists. Telemedicine is a subset of telehealth.
• Telehealth is broader, and includes remote services provided by health care professionals like nurses, pharmacists and social workers. It encompasses education, medication support, care coordination and health monitoring.

Public Health Challenges for Rural Communities

Rural communities face specific issues — such as provider shortages, gaps in infrastructure and economic challenges — that limit patients’ access to timely, high-quality care. Clearly identifying these challenges helps clarify why health outcomes often differ between rural and urban areas and points toward areas where solutions are most needed.

Fewer Doctors and Specialists

At the national level, a gap in physician availability persists between urban and rural areas. Rural areas average about 68 physicians per 100,000 people, compared with roughly 80 per 100,000 in urban areas, according to the National Health Resources Association. 

Access to doctors varies by state. For example, California law considers one provider for every 2,000 people enrolled in a health care service plan adequate, but primary care practitioner (PCP) access data reported by Let’s Get Healthy California shows that the number of available physicians varies significantly throughout the state. Counties that do not meet the state standard are considered health professional shortage areas (HPSAs). 

Here are some key insights from the data:

• Rural areas such as Alpine County and Sierra County fall short of meeting the one PCP per 2,000 resident standard, earning HPSA designation.
• Counties that meet or exceed the standard are primarily urban, for example, San Francisco County and Marin County.

With fewer health care providers in rural communities than in cities, it’s harder for residents to get the care they need close to home. It also means they have fewer options for specialty care.

Challenges in Attracting Health Care Workers            

Rural communities face difficulties building and sustaining a stable health care workforce. Limited resources and geographic isolation can make recruitment and retention challenging for health care facilities, leading to the following issues:

• Shortage of physicians, nurses and mental health providers overall
• Limited access to specialists such as neurologists and psychiatrists
• Higher workloads that can lead to provider burnout, affecting the quality of care delivered

Infrastructure and Technology Gaps

More than 100 rural hospitals — approximately 4 percent of all rural hospitals — closed between 2013 and 2020, according to the U.S. Government Accountability Office, making health care increasingly difficult to access in rural America. The rural hospitals that remain open often have to operate with constrained resources, which limits the services they can offer and their ability to expand their care options.

Rural health care facilities often face the following issues:

• Limited availability of diagnostic tools and specialty clinics
• Inconsistent broadband access 
• Underdeveloped telehealth infrastructure
• Training barriers that slow the adoption of telehealth in rural communities

Transportation and Travel Burdens             

The distance they need to travel to visit health care facilities remains one of the most immediate practical barriers to care for rural residents. Even when services are available, reaching them can be difficult, especially for patients who require frequent visits. Rural residents are often unable to access care due to:

• Long travel times for routine and specialty care
• Transportation costs that add to the overall burden of accessing care
• Missed appointments and delayed follow-up

Economic Barriers             

The cost of health care plays a significant role in whether rural residents seek care. Patients with lower incomes and insurance gaps can find it difficult to afford the health care they need, even before travel and time away from work are considered. Examples of economic barriers to health care in rural areas include:

• Lower average incomes 
• Higher rates of underinsurance
• High out-of-pocket costs
• Travel expenses

Managing Chronic Diseases and Preventive Care             

Chronic conditions are more common in rural communities and are often harder to manage due to patients’ limited access to consistent care. Preventive services and early interventions are less accessible to people in these communities, which can lead to worsened outcomes over time. Key challenges include:

• Higher rates of diabetes, hypertension and obesity
• Limited access to preventive services and routine checkups
• Increased risk of complications and reduced quality of life

Mental Health Access and Stigma             

Rural areas face a growing mental health crisis. Shortages of mental health providers in rural areas — about 65 percent of rural counties lack a psychiatrist, and 81 percent do not have a psychiatric nurse practitioner — mean that mental health services are limited. Mental health access challenges in rural communities include:

• Ongoing shortages of mental health professionals
• Stigma that discourages individuals from seeking help
• Higher rates of untreated mental health conditions, substance use and suicide compared to urban populations

How Does Telehealth Impact Rural Communities?

The availability of telehealth services impacts rural communities by helping residents access care that would otherwise be difficult to obtain. By reducing their travel demands and connecting patients with providers and specialists outside their local area, telehealth services help rural communities manage their provider shortages, offer care to patients sooner and maintain a more consistent treatment and follow-up regimen with patients.

Improved Access to Care Despite Provider Shortages             

With access to telehealth services, rural patients can more easily connect with primary care providers and specialists such as psychiatrists, neurologists and endocrinologists, strengthening rural communities’ health care infrastructure. Without telehealth, these providers can be hard to find nearby, and scheduling follow-up care and routine check-ins is more difficult.

Improved Emergency Decision-Making             

Telehealth is being used to reduce care delays during emergencies in rural areas by helping clinicians make faster, more informed decisions. Telehealth’s impact on rural hospitals shows that virtual consultations improved clinical judgment, reduced unnecessary patient transfers and allowed more patients to receive care locally. For time-sensitive emergencies such as stroke and trauma, earlier decision-making can make a meaningful difference in outcomes for rural patients. 

Expanded Access to Mental Health Services

While rates of mental illness are similar in rural and urban areas, access to mental health services is not. Telehealth has expanded mental health care availability in rural communities where behavioral health providers are often scarce. 

A Rural Health Information Hub (RHIhub) report on mental health in rural communities notes that telehealth options help address mental health care access challenges made worse by provider shortages, high no-show rates and low reimbursement levels. The availability of mental health care delivered via telehealth allows patients to receive care from home and improve the continuity of their treatment for anxiety, depression and substance use disorders.

Examples and Benefits of Telehealth in Rural Communities

Telehealth usage surged during the COVID-19 pandemic, and it remains a trusted source of care for patients throughout the United States, including in rural areas. 

For example, in one rural Midwestern community, telehealth use jumped from 5 percent before the pandemic to 42.1 percent at its peak. Today, about 21.8 percent of people still use telehealth services in this community, with primary care visits remaining the most popular type of telehealth appointment. 

How might rural residents benefit from telehealth? The key benefits of telehealth in rural communities are:

• Giving more people access to care
• Addressing health disparities caused by socioeconomic and other factors
• Helping people take control of their health outcomes
• Promoting a culture of health and wellness

Below are some examples of the advantages that are offered by telehealth in rural communities.

Emergency Care in Rural Hospitals 

High-quality care is within reach for 32 rural emergency departments in South Dakota, North Dakota and Minnesota with Sanford Health’s tele-emergency program. Clinicians in these regions use telehealth carts and a virtual care hub to consult with experts on urgent cases such as patients experiencing strokes, burns and traumatic injuries. 

This program improves access to specialized emergency care in rural hospitals, speeds up decision-making and helps save lives in rural areas. It also delivers operational benefits, such as enhancing care coordination and providing ongoing education for clinicians.

Improved Disease Outcomes             

Rural health care providers often lack specialized knowledge to effectively treat diseases like hepatitis C. Additionally, patients with complex chronic conditions often struggle to reach urban specialists due to long wait times and travel issues. 

Project ECHO, which has become a national model for health care collaboration in rural and underserved areas, helps solve these issues by connecting disease-specific specialists with rural care teams through regular virtual sessions. The project helps build a supportive learning network where everyone shares knowledge and improves patient care in real time.

Mental Health Support for Rural Students        

Telehealth services are expanding access to mental health care for students in rural communities through school-based programs. At the University of Kansas Medical Center, the Telehealth Regional Outreach to Communities, Kids and Schools (Telehealth ROCKS) program provides telehealth services that help schools deliver mental health care to support students experiencing stress, depression and learning challenges.

Resources About Telehealth in Rural Communities

The following resources offer additional context and information, covering everything from the definition of telehealth to strategies and tools that help reduce health inequities.

• Centers for Disease Control and Prevention, “Rural Public Health Strategic Plan”: This guiding resource is designed to improve health outcomes in rural communities, outlining priority strategies and actions to reduce health disparities.
• Centers for Disease Control and Prevention, “Rural Health Disparities: Contemporary Solutions for Persistent Rural Public Health Challenges”: This resource examines persistent public health challenges in rural communities and highlights current community-driven strategies to address chronic conditions such as obesity, diabetes and cancer.
• Comparative Effectiveness Review, No. 254, “Improving Rural Health Through Telehealth-Guided Provider-to-Provider Communication”: This study reports on improved patient outcomes in certain clinical scenarios, such as outpatient care for depression or diabetes, where telehealth interventions enhanced access to expertise and high-quality care.
• Mayo Clinic, “Telehealth: Technology Meets Health Care”: This article discusses how telehealth tools, including patient portals and wearable monitoring devices, support more effective health management.
• RHIhub, Barriers to Health Promotion and Disease Prevention in Rural Areas: This brief resource highlights key social determinants that create obstacles to health care access in rural communities.
• RHIhub, Rural Telehealth Toolkit: The tool kit brings together evidence-based models and practical resources to help organizations implement telehealth programs that address common challenges in America’s rural communities.
• Telehealth.HHS.gov, Telehealth for Rural Areas: This best practice guide offers tools and resources to help health care providers use telehealth effectively in rural communities.

Building Equitable Rural Health Care Through Telehealth

Telehealth has become a practical tool for improving the health of people living in rural communities, but its impact depends on public health and health care professionals understanding the challenges rural residents face, identifying why they are at greater risk and thoughtfully implementing strategies to address the challenges. 

Advancing more equitable health outcomes requires attention to core dimensions of access, including ease of use, service availability, patients’ comfort, affordability, alignment with patients’ needs and a clear understanding of how to use telehealth services. When these factors are addressed together, telehealth can address gaps in rural health care delivery. 

Public health professionals play a central role in improving rural residents’ health outcomes by designing policies and systems that support resilient, inclusive and healthy rural populations and helping communities adapt to the changing health care and technology landscapes.