Frontier Extended-Stay Clinic Demonstration: Opportunities for and Barriers to Creating a New Provider Type

Extremely remote clinics—those at least 75 miles away from a higher level of service—often have to provide care for patients for four hours or more. Sometimes that happens because it's safer, more convenient, or more efficient; sometimes it's due to transportation barriers. Most of these clinics are not reimbursed for such extended encounters.

In 2004, the Health Resources and Services Administration (HRSA) Office of Rural Health Policy (ORHP) funded the Frontier Extended Stay Clinic (FESC) demonstration at five clinics—four in Alaska and one in Washington—to test the operational viability and financial sustainability of a clinic model that would be equipped and staffed to provide emergency and extended stay encounters in addition to primary care in remote areas. In 2009, two frontier critical access hospitals in Montana joined this project for comparison purposes. Also, the Center for Medicare and Medicaid Services has initiated a three-year demonstration project allowing FESCs to receive additional Medicare reimbursement for extended stay encounters that meet certain criteria.

To allow evaluation of the FESC model, data was collected for each extended encounter. After four years, there were 1,679 FESC encounters at the five clinic sites. The mean length of these encounters was 9.4 hours—9.6 hours for monitoring and observation encounters and 9.0 hours for encounters resulting in transfers. Monitoring and observation encounters made up 62.7% of the project's overall encounters.

While 42.6% of all FESC encounters initially resulted in transfers, a look at monitoring and observation encounters reveals that occasionally when patients' conditions worsened unexpectedly or did not improve as expected, there were additional transfers. Among encounters that began as monitoring and observation, 10.5% resulted in transfers to facilities with a higher level of services. Almost half (47.6%, n= 800) of FESC encounters resulted in patients being discharged, without need for non-urgent follow-up referral or transport.

The five most frequent diagnoses at discharge for FESC encounters were cardiovascular (13.7%), gastrointestinal (13.7%), injury (10.8%), substance abuse (8.9%), and pneumonia/bronchitis (8.9%), accounting for 56.1% of all diagnoses. Cardiovascular, gastrointestinal, and injury were among the top five discharge diagnoses for monitoring and observation as well as transfer encounters.

Based on project trends and comparison data, FESC is a viable model for emergency and extended-stay care in frontier areas.