defibrillators in rural communities (HRSA, 2003). Lasting improvement in the quality of EMS will require that new programs be designed with evidence-based standards and procedures, a systems approach to functions and operations, implementation of cutting-edge information and communications technology and telemedicine systems to supplement care, and clearly defined methods for measuring quality and outcomes. An IOM study on EMS and emergency room care is currently in progress, with a series of reports to be released in 2005–2006.


In the majority of rural communities, the hospital is the central focus of health care delivery, often providing outpatient, home health, skilled nursing, and other long-term care in addition to inpatient care. Hospitals have had a major role in ensuring the provision of health services in rural areas where no other providers are available, and have been an essential part of the social and economic identity of the local community, often constituting the largest or second-largest employer in the area (Moscovice and Stensland, 2002). Statistics from the American Hospital Association’s (AHA) 2000 Annual Survey indicate that, of the total of 4,927 nonfederal, acute care community hospitals in the United States, 44 percent or 2,178 are located in rural counties. Over 70 percent of hospitals with 100 or fewer beds are located in rural areas (see Table C-3) (Colgan, 2002).

TABLE C-3 Hospitals in Rural Areas, Year 2000

Hospitals by Bed Size



Under 25









SOURCE: Colgan, 2002.

The structure, function, and role of hospitals in the U.S. health care system have been changing rapidly and significantly. From the 1980s through the mid-1990s, about 1,072 hospitals were confronting serious financial difficulties and were forced to close, convert, or merge; of these, 438 were rural (Ricketts, 1999). Rather than close down, many rural hospitals converted to modified inpatient health care facilities and expanded outpatient services (Ricketts, 1999).

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