By: Lydia Kotowski, JD, MHA, California Telehealth Resource Center
Chronic disease remains one of the most persistent and costly challenges facing rural healthcare systems. In communities where long travel times, provider shortages, and economic barriers hinder timely access to care, rural hospitals are often left to manage complex, ongoing health conditions with limited resources. But as technology evolves, so too does the opportunity to turn the tide. From telehealth to AI-enabled clinical decision support, smart digital health tools are offering rural providers new ways to deliver timely, connected, and coordinated care—without requiring patients to leave their communities.
The Challenge: Chronic Disease and Access Gaps in Rural Communities
Rural hospitals serve as lifelines for millions of Americans, yet they often face uphill battles in managing chronic diseases such as diabetes, hypertension, COPD, and heart disease. The challenges are complex:
- Higher disease burden: Rural populations experience higher rates of multiple chronic conditions compared to urban counterparts, often due to socioeconomic disparities, limited transportation, and environmental factors.
- Limited access to specialty care: Many rural hospitals struggle to recruit and retain specialists. In some regions, patients must wait weeks or travel hours to see an endocrinologist, cardiologist, or pulmonologist.
- Healthcare workforce shortages: Rural providers are stretched thin, and managing chronic care requires time, follow-up, and multidisciplinary coordination that many facilities are not resourced to support.
- Barriers to in-person care: Geographic isolation, weather disruptions, and transportation insecurity often delay needed follow-up or monitoring, leading to complications and costly ER visits.
The Opportunity: Digital Health Tools as a Force Multiplier
While no single solution can solve the rural health care crisis, a thoughtful mix of digital health tools can help rural hospitals scale their reach, expand access, and deliver smarter chronic disease management. Here are a few high-impact technologies that rural hospitals can begin exploring:
1. Telehealth: Closing the Distance to Care
Audio-video and audio-only visits allow rural hospitals to bring clinical expertise directly into the homes of patients. For chronic disease, telehealth can:
- Support regular check-ins with primary care or nurse case managers
- Facilitate virtual specialist consultations via partner hospitals or academic centers
- Reduce no-show rates and increase care plan adherence
Tip: Start small. Find one area where telehealth could have a significant impact and pilot a program there. Review CTRC’s Hybrid Virtual Care Considerations HERE.
2. Remote Physiological Monitoring (RPM): Continuous Care Between Visits
RPM uses connected devices—such as glucometers, blood pressure cuffs, and pulse oximeters—to transmit patient data to care teams in real time. This enables proactive outreach and faster response to health deterioration. This is a critical tool as you move to new value-based payment models in the face of the chronic disease crisis of diabetes and cardiovascular disease.
- Ideal for managing diabetes, hypertension, and CHF
- Can reduce readmissions and ER visits
- Offers a scalable way to monitor large patient panels with fewer staff
Tip: Partner with vendors who offer end-to-end support, including device deployment, data management, and patient education to ensure sufficient technical assistance. AI increasing is becoming a critical feature. Review CTRC’s Healthcare AI Vendor Checklist HERE.
3. Remote Therapeutic Monitoring (RTM): Supporting Behavioral and Physical Health
RTM tracks data on how well a patient is adhering to a treatment plan, such as adherence to taking prescription drugs. It offers:
- Insight into patient activity and therapy compliance
- Reimbursement pathways for non-physician time
- Opportunities for virtual rehab and behavioral health coaching
Tip: Use RTM tools to support patients with chronic pain or COPD who may struggle to attend regular in-person therapy. If you need help understanding Medicare billing, watch CTRC’s webinar on this topic HERE and consult with the AMA’s Digital Medicine Clinical Scenarios: Coding Handbook HERE.
4. e-Consults: Specialist Expertise Without the Wait
Electronic consultations (also called Interprofessional Consultations) enable rural providers to get asynchronous specialist input within days, not weeks. By sending clinical questions and relevant records through secure platforms, primary care teams can:
- Resolve cases without needing a patient referral
- Reduce unnecessary travel and wait times
- Strengthen local capacity for managing specialty care
Tip: Identify high-volume referral areas—like dermatology or endocrinology—to pilot e-consults. Review CTRC’s Payment Guide to learn more about e-Consult reimbursements for Medi-Cal and other public payors HERE.
5. AI-Enabled Clinical Decision Support: Helping Providers Make Smarter Calls
AI-driven tools can assist rural clinicians by flagging care gaps, suggesting treatment pathways, and identifying patients at high risk of hospitalization or disease progression.
- Helps standardize chronic care across providers
- Can be embedded into EHR workflows or care management software
- Supports earlier intervention for complex patients
Tip: Look for AI solutions that integrate with your existing health IT infrastructure and emphasize clinical transparency. Review CTRC’s AI Toolkit HERE.
Final Thoughts: A Roadmap Toward Smarter Rural Care
The path toward fully integrated digital health in rural hospitals won’t be identical for every community though they all lead towards the same destination: timelier, coordinated, and patient-centered care, provider satisfaction, and financial sustainability.
Chronic disease doesn’t have to be a losing battle. With smart, scalable digital health tools, rural hospitals can shift from reactive care to proactive health management—and ensure that every patient, regardless of ZIP code, has access to the care they deserve.
To learn more or request technical assistance, visit www.caltrc.org or reach out to our team directly.
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