Extending Rural Primary Care Capacity

Rural Healthcare Innovation Summit, Episode 3: Castañer General Hospital, Puerto Rico

In early December 2025, eight rural health systems from across the United States and Puerto Rico gathered in Hutchinson, Kansas for a two-day Rural Healthcare Innovation Summit focused on practical strategies to strengthen the rural healthcare workforce. Each organization shared real-world approaches to improving clinician and staff recruitment, retention, and well-being, with the goal of spreading actionable ideas to other rural communities facing similar challenges.

The Healthcare Reframed team was fortunate to be invited to the conference to film a roundtable conversation with the participants, and we have created a series of videos sharing insights from individual sites who presented at the meeting. In addition, we are delighted to be able to share here a series of excellent case studies written to accompany the videos by a team under the leadership of Erin E. Sullivan, PhD. We hope these stories spark ideas, encourage connection, and support others working to strengthen rural healthcare. If you find them valuable, please share them with colleagues and partners who may benefit from the approaches featured here.

Today we are sharing case study #3, from Castañer General Hospital in Puerto Rico. The video conversation can be found on the Healthcare Reframed website, on YouTube, and on Spotify. This case study was written by Yoann Sophie Jean-Felix, MPH and Erin E. Sullivan, PhD, with contributions from site leaders Giovani Ortiz Pagan, CEO, and Jose Rodriguez, Medical Director.

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Site and Community Snapshot

Castañer General Hospital is a rural, safety-net health provider in Puerto Rico’s central mountainous region. The organization serves three municipalities that are among the most socioeconomically disadvantaged on the island: as of 2025, approximately 95% of residents live below 200% of the federal poverty level. Castañer’s service area is characterized by rugged terrain, limited transportation infrastructure, frequent flooding, and restricted access to broadband internet. Travel to tertiary or specialty care frequently requires 45 to 90 minutes along narrow secondary roads, positioning Castañer as the primary and often sole point of access for comprehensive healthcare services in the region.

Founded in 1942, Castañer General Hospital transitioned to a Federally Qualified Health Center (FQHC) model in 1976 and has operated continuously in the region for over 80 years. The system operates three FQHC clinics, a 24-hour emergency department, and an inpatient unit with 33 licensed beds (with a very low daily census). Castañer serves approximately 12,000 unique patients annually and generates roughly 60,000 total encounters per year across its FQHC clinics and emergency department. The organization employs approximately 300 staff and provides a broad array of services, including primary care, obstetrics, pediatrics, dental care, behavioral health, ophthalmology, radiology, laboratory services, and three on-site pharmacies supported by the 340B Drug Pricing (Matthewman et al., 2021).

Castañer’s payer mix is heavily weighted toward public insurance, with approximately 68% of patients covered by Medicaid, 18% by Medicare, and only 12% by private insurance. A small portion of uninsured patients are served through grant-supported care. This distribution reflects the broader socioeconomic conditions of the communities served. As one member of the health system leadership explained,

“Out of 78 municipalities in Puerto Rico, the three we serve are among the poorest on the island.”

The patient population also includes approximately 2,700 migratory and seasonal agricultural workers, reflecting the region’s agricultural economy and further underscoring the importance of accessible, locally delivered primary and specialty services.

Workforce Challenge and Pre-Intervention State

Castañer General Hospital faced persistent workforce shortages, particularly among physicians and specialists. Recruitment was constrained by geographic isolation, limited housing and community amenities, and competition from urban hospitals and insurance-owned outpatient centers that could offer substantially higher compensation. While the organization achieved relative stability in nursing and allied health staffing, often through internal training and advancement, physician recruitment and retention remained significant challenges. As the Chief Medical Officer stated, “If something happens, they call my phone. The hospital does not have any admitting physician right now.”

Limited physician availability required reliance on telehealth tools and on-call arrangements, underscoring the vulnerability of Castañer’s rural staffing models in an underserved region.

At program initiation, the hospital lacked an on-site admitting physician, had no internal psychiatry coverage, and relied heavily on teleconsultation and emergency call coverage. Island-wide trends, including high rates of cash-only psychiatric practices and near-capacity utilization of mental health facilities across Puerto Rico, compounded specialty shortages. These workforce constraints had direct implications for access, continuity, and quality of care. Patients with chronic illness, mobility limitations, or transportation barriers frequently experienced delayed or foregone care. For residents in flood-prone or geographically isolated areas, accessing facility-based services was often not feasible.

Workforce Innovation: Home-Based, Team-Driven Telehealth Care

In response to these challenges, Castañer General Hospital implemented a home-based telehealth care model designed to extend clinical capacity without requiring additional on-site physicians. The Optimal Bidirectional Care (OBC) intervention established five mobile care teams, each composed of one registered nurse and two community health workers (CHWs). These teams conducted structured in-home assessments and facilitated real-time telehealth visits with physicians, allowing the organization to reach patients in remote mountain communities with limited transportation and internet access.

The primary objectives of the intervention were to (1) expand access to primary and chronic disease care for homebound and hard-to-reach patients; (2) mitigate the impact of physician shortages through task sharing and team-based care; (3) systematically integrate social determinants of health into clinical workflows; and (4) improve chronic disease outcomes while stabilizing workforce demand. Guiding principles included patient-centered care, formal integration of CHWs as core members of the clinical team, and the strategic relocation of care delivery from clinic settings to patient homes.

Program Design and Implementation

Governance and Leadership

This was a physician-led program overseen by the Chief Medical Officer. Clinical protocols, workflows, and quality standards were developed over a one-year planning and training period before patient enrollment. Nurses received expanded training in physical assessment, chronic disease management, and telehealth facilitation. CHWs were formally assigned responsibilities related to home assessment, social needs screening, care coordination, and follow-up.

Program Components and Practices

Each mobile team conducted approximately four to five home visits per day. On visit days, the teams arrived about 30 minutes before scheduled telehealth appointments to assess home conditions, identify social determinants of health, and establish internet connectivity using mobile or satellite equipment. Community health workers (CHWs) evaluated living conditions, food security, housing stability, and access to utilities, while registered nurses performed vital signs, screenings, laboratory specimen collection, and comprehensive medication reconciliation-- often identifying discrepancies between reported and actual medication use. One nurse noted,

“When we go to the house, the story changes. What we see there directly affects clinical decision-making.”

All findings were documented in the electronic health record prior to the physician conducting the synchronous telehealth visit using the real-time data gathered in the patient’s home. Care plans were developed collaboratively among physicians, nurses, and CHWs, emphasizing patient education, medication adherence, and continuity of care. For selected patients, remote monitoring devices were deployed when connectivity allowed, enabling ongoing management of chronic conditions between visits.

Partnerships and External Relationships

The model incorporated teleconsultation partnerships in neurology and ophthalmology, leveraging robotic and AI-supported platforms. Additional specialty teleconsultation capacity was under development. Castañer also served as a training site for rotating medical residents, nurses, pharmacists, social workers, and psychologists, and was preparing to launch a rural family medicine residency program.

Early Outcomes and Impact

The model enabled physicians to manage a larger patient panel without increased on-site staffing, effectively extending clinical reach through team-based care. Five mobile teams supported over 600 patients annually. Preliminary operational data suggested reductions in avoidable utilization and improved care coordination, although reimbursement remained constrained under Puerto Rico’s capitated Medicaid payment model. Puerto Rico operated under a capitated Medicaid payment structure, in which providers received a fixed per-member-per-month (PMPM) payment intended to cover all services. Home visits and mobile team operations were financed out of this fixed payment, creating pressure on margins. The organization was exploring carve-outs or supplemental payment arrangements with managed care plans to offset operational costs while maintaining the model’s access and quality gains.

Clinical Outcomes

Between program initiation and the most recent reporting period (2025), the program served more than 600 unique patients and conducted over 1,800 home-based visits. Among patients with diabetes, rates of glycemic control (A1C <9%) improved from approximately 60% pre-intervention to over 70% in later reporting periods. Patients with significant transportation barriers received integrated medical, pharmacy, and behavioral health services in their homes.

Lessons Learned

Several factors appeared to enable successful implementation of the home-based, team-driven telehealth model at Castañer General Hospital. Strong physician leadership and clear clinical governance provided a framework for task sharing in a context of chronic physician scarcity. Upfront investment in training nurses and community health workers, coupled with explicit protocols and documentation standards, supported safe delegation of clinical and social care functions to non-physician team members. Decades of trust between the organization, local faith communities, and residents further facilitated home entry, acceptance of telehealth technology, and engagement with care plans.

At the same time, persistent structural barriers shaped both implementation and impact. Unreliable broadband and cellular coverage in mountainous areas limited real-time connectivity, requiring redundant workflows, satellite-based solutions, and flexibility in scheduling. Misalignment between Puerto Rico’s capitated Medicaid payment model and the resource requirements of mobile, home-based care meant that the program operated within tight financial constraints; the fixed per-member-per-month payment did not explicitly recognize the additional costs of home visiting teams, transportation, or remote monitoring. Operationally, shifting care from facility-based to home-based settings demanded new logistical competencies in routing, safety, inventory management, and interprofessional communication.

Several lessons from Castañer appeared transferable to other rural and resource-limited settings. First, structured team-based task sharing, anchored in clear protocols and supported by telehealth, offered a viable strategy for extending primary care capacity when on-site physicians were scarce. Second, systematic assessment of social determinants of health in patients’ homes materially altered clinical decision-making, revealing discrepancies in medication use, food security, and living conditions that were not apparent in clinic-based encounters. Finally, sustainable scaling of such models appeared to depend on payment reforms and contracting strategies that explicitly recognized home-based care, mobile teams, and CHWs as integral components of the delivery system rather than ancillary services.

Looking Ahead

This case demonstrated how rural safety-net systems facing severe workforce constraints could leverage team-based, home-centered telehealth models to expand access, improve outcomes, and stabilize care delivery in resource-limited settings. The next steps planned include expanding specialty teleconsultation services, implementing a rural family medicine residency program, and continuing to develop internal workforce pipelines. Sustainability strategies focus on codifying workflows, strengthening academic partnerships, and pursuing alternative reimbursement arrangements to support home-based care.

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References

Matthewman, S., Spencer, S., Lavergne, M. R., McCracken, R. K., & Hedden, L. (2021). An environmental scan of virtual “walk-in” clinics in Canada: Comparative study. Journal of Medical Internet Research, 23(6), e27259.