The RURAL Playbook: Rescuing Rural Health Care
How MHCDS students saved a Colorado hospital from collapse and created a blueprint for saving independent hospitals nationwide.
By Rachel Hastings
In the heart of rural America, a health care crisis simmers. Independent hospitals, once pillars of their communities, are struggling financially and shutting their doors as large health care corporations pull resources out of underserved areas. Access to care is dwindling, leaving residents vulnerable and health care professionals grappling with the weight of a system in distress. For Kelly Johnston MHCDS’25, a self-proclaimed “ranch kid” turned health care financial expert, this crisis is a call to action.
Johnston, who built a consultancy focused on revitalizing rural hospitals, saw firsthand the struggle to balance patient care with financial realities. “A lot of hospitals have great intentions for patient and population health but can’t make the math work,” she explains. “My goal is to help them connect those dots.”
Driven by this mission, Johnston enrolled in the Master of Health Care Delivery Science (MHCDS) program at Dartmouth, delivered jointly by the Tuck School of Business and the Geisel School of Medicine. The 12-month program, which enrolls medical practitioners as well as health care leaders and executives, emphasizes an interdisciplinary approach to problem-solving. The program culminates in a final deliverable where groups of students tackle real-world challenges facing health care, the Action Learning Projects (ALPs).
Johnston and her team’s ALP, titled “The RURAL Playbook,” focused on St. Vincent Health, an eight-bed critical access hospital in Colorado teetering on the brink of collapse. With her team of five, which included physicians specializing in utilization and volume management and a Medicare billing expert, Johnston and her ALP team identified three key challenges: patient registration errors, missed Medicare reimbursements, and underutilized beds. Together, those issues were causing the hospital to lose millions in potential revenue each year.
“The common theme was lack of education,” Johnston explains. “The facility wasn’t tracking bad debts, the receptionists handling patient registration weren’t aware of their role in the revenue cycle, and there wasn’t a real process for using data to make utilization decisions.”
The team implemented targeted training and meticulous process improvements, including new utilization data dashboards and regular review meetings, to rectify issues severely impacting revenue.
The results were lifesaving.
Within just four months, St. Vincent Health saw a surge in revenue that transformed a projected $3 million loss in 2023 into a projected profit for 2024, rescuing the hospital from demise and ensuring continued access to care for an entire community.
But Johnston and her team didn’t stop there.
“We knew St. Vincent would be the host, but our goal from the start was to address a broader problem in rural healthcare,” she says. “Every team member was so passionate about allowing rural hospitals to remain independent.”
To scale what they learned at St. Vincent, Johnston’s team distilled their insights into the RURAL Playbook, a framework for optimizing operational revenue cycles in rural hospitals. The playbook, which they have already shared with community access hospitals nationwide, is garnering overwhelmingly positive feedback, and the team hopes to expand its content and distribution.
“Our hope is that this project has a life far beyond MHCDS,” Johnston says. “The scope of needs in these rural areas is immense.”
The RURAL Playbook is a shining example of the transformative power of the MHCDS program and its unique approach to action learning. By bringing together diverse perspectives and fostering collaboration, MHCDS helps empower health care leaders to look outside the traditional boundaries of their roles to drive meaningful change. This interdisciplinary learning model, as seen with the incredible turnaround of St. Vincent, has proven to be a catalyst for creating tangible impact throughout health systems and their surrounding communities.
“Health care is incredibly siloed,” says Katherine Milligan D’90, T’07, associate dean for Health Care Management Education who also teaches the ALP course. “Crossing functional lines is immensely valuable. All MHCDS students, regardless of background, are united by a desire to transform health care. The ALPs provide a platform to apply their learning, collaborate, and prepare for an even greater impact.”
For MHCDS students, ALPs are often the highlight of the program. Completing an ambitious project with real-world consequences over nine months—while balancing coursework and busy full-time roles—isn’t easy, but the challenge builds powerful bonds between participants.
“The people make the program,” says Johnston. “My cohort was incredible. And working closely with physicians—who are often in contention with financial leaders within the hospital setting—completely transformed my outlook and how I engage with the doctors I work with.”