Care in the country: A multi-case study of long-term sustainability in four rural health centers

Context: This study is a follow up to a national evaluation of rural primary care programs conducted from 1978 to 1983.

Purpose: The study aims to identify factors that allowed rural primary care programs to continue operating despite facing a variety of financial and other barriers that threatened their long-term sustainability.

Methods: This study uses a multi-case study design. In a deductive process guided by themes from the earlier literature, historical files were reviewed twice and information related to the themes of long-term organizational sustainability were taken from the files and used to construct narratives for four rural primary care programs. Keywords identified from the file materials were used to conduct an internet search for current information on each program. This information was included in the narratives. The narratives were compared and analyzed to identify major themes.

Findings: The themes identified included the presence of physician advocates with long tenure, a willingness of the program to adopt innovative practices, organizational flexibility that favored continued pursuit of the organizational mission over other less relevant aspects of the program, and integration with other larger community providers (e.g., hospitals) to increase efficiency.

Conclusions: Due to the difficult nature of serving the populations they do, the future of these programs is uncertain after those who have championed have left. Identifying future generations of physician advocates is a crucial next step in developing the rural primary care workforce.