Kenny O’Neill
Managing Director
Kenny O'Neill brings 18 years of global healthcare consulting experience, having advised boards and executive teams across the healthcare continuum on strategy, transformation, value creation and growth initiatives.
Article
Beyond hub-and-spoke: The rural healthcare network of tomorrow
Key points
For decades, rural healthcare has been organized primarily around hospitals and clinics connected through traditional referral relationships. But the pressures facing rural providers challenge that structure. Rural communities today are asking what a more sustainable approach should look like.
The hub-and-spoke model is familiar to rural healthcare, concentrating complex services centrally while extending others into local communities. But today’s pressures demand an evolution of that approach. The network of tomorrow must combine physical care sites, digital capabilities, and trusted community connections to deliver the right care in the right place.
That requires adding a new element: the node. The result is a hub-spoke-node network built around the patient.
The hub—the traditional hospital—remains the center of clinical capability. It provides comprehensive inpatient and emergency care, including, in many instances, surgery, advanced diagnostics, and other services requiring scale. Spokes extend care through primary care, urgent care, imaging centers, and other localized services—away from the hospital, but still in a traditional healthcare setting. Nodes extend the network beyond those traditional settings into places where people already live their lives.
Nodes are trusted points of connection between patients and the healthcare system. They might include pharmacies, libraries, churches, schools, or other familiar locations equipped to connect patients with services such as remote monitoring. A node can also be human: community health workers, retired healthcare professionals, and other trusted residents who can help patients navigate technology and connect with appropriate care.
The node is not just another healthcare facility. Its purpose is connection. For a patient who lives an hour from the nearest hospital, and who might be skeptical of the healthcare system to begin with, the node brings care to where people are most comfortable receiving it. This addresses physical distance while creating an opportunity to strengthen trust through familiar community relationships.
Redesign services around what belongs where
Building a hub-spoke-node network requires deliberate decisions about where services belong.
Some should remain hub-centric. For instance, an analysis of Vizient’s Clinical Data Base (CDB) found mortality rates for one complex cardiac procedure ranging from 7.6% at hospitals performing fewer than 10 cases annually to 1.2% at hospitals performing more than 250. This demonstrates that for highly complex care, concentrating clinical expertise and volume at a regional center can produce better outcomes than attempting to maintain the same capability everywhere.
Other services should remain local. CDB analysis has found no material difference in outcomes between rural and other hospitals for certain outpatient procedures in general surgery and orthopedics. These services also can provide financially important procedural volume for rural facilities. Keeping appropriate services as local as possible therefore can support access without compromising outcomes.
Then, consider which functions do not require a traditional clinical setting at all. A community location—say, a grocery store or a prominent local employer—can provide a connection to telehealth, remote monitoring, or medication support. Community champions and other trusted intermediaries can help patients navigate the network. The node allows appropriate functions to move even closer to patients without requiring another facility.
The workforce should follow the care model. Hubs can concentrate scarce clinical expertise, spokes can rely more heavily on generalists and advanced practice providers, and nodes can draw on community-based resources for functions that do not require clinicians at all. Rather than attempting to reproduce the same workforce and services in every community, the network deploys them where they can create the greatest value.
The economics can change as well. Nodes can expand access without requiring the capital and staffing associated with another traditional clinical site. Their value may be amplified under value-based arrangements, in which easier access to preventive services and chronic disease management can reduce avoidable higher-cost utilization. As organizations assume greater responsibility for the health and total cost of care of a population, bringing appropriate services closer to patients becomes both a clinical and an economic strategy.
Preserve the human connection
The question for rural leaders, therefore, becomes: What belongs where? This will vary by community and region. Answering it with clinical outcomes, access, and financial sustainability in mind can turn hub-spoke-node from a collection of access points into an integrated rural care delivery model.
Technology will enable the model, but it will not make patients use it. That is particularly important in rural communities, where deep community connections remain one of healthcare organizations’ greatest strengths. A technologically sophisticated care model will accomplish little if patients do not trust it or cannot navigate it.
This is where nodes demonstrate their highest value. A trusted intermediary can provide something that a telehealth platform cannot: a human connection. Community champions can help patients understand how to access services and connect with the appropriate level of care. The community itself becomes part of the care delivery infrastructure. These relationships already exist in many rural regions; the hub-spoke-node construct makes them an intentional component of the operating model.
The model requires rural providers to become better partners. No individual hospital can own every capability, and partnership must become a core competency.
Tomorrow’s rural healthcare system will still need hospitals. Those hospitals will create greater value as anchors of networks that extend clinical expertise, trusted relationships, and access beyond their walls.
Your 60-second read
- Rural healthcare must evolve beyond traditional hub-and-spoke models to include community-based “nodes” that bring care closer to patients.
- Health systems should determine which services belong at the hospital, which can remain local, and which can move into community settings.
- Nodes can expand access without the cost and staffing requirements of traditional clinical sites.
- Success depends on trusted community relationships and partnerships as much as technology.
What care belongs where?
A sustainable rural hub-spoke-node network requires deliberate decisions about where services should be delivered. Three considerations can guide those decisions:
- Keep it local. Can the service be delivered locally with comparable clinical outcomes while supporting the hospital’s financial viability? Some outpatient general surgery and orthopedic procedures may fall into this category.
- Bring expertise to the patient. Does the patient need specialty expertise without requiring the specialist to be physically present? Virtual specialty consultation can support local primary care teams managing chronic and complex conditions.
- Concentrate or partner. Does quality depend on sufficient clinical volume or capabilities that cannot be replicated broadly? Highly complex care may be better concentrated at regional centers supported by clear referral and transfer pathways.
The objective is neither maximum local care nor maximum centralization. Rather, it is a network that matches each service with the setting best able to deliver access, quality, and long-term financial sustainability in a way that places the patient at the center of care.
What a node could look like
Consider a rural health system whose patients often live significant distances from traditional healthcare facilities. Rather than building another clinic, the system partners with a local bank to place private telehealth stations in several rural branches.
The locations offer an unusual combination of advantages: they are familiar community institutions, already operate as a network, and may be considerably closer to patients than the nearest healthcare facility. At each location, patients can use a private telehealth station to connect with a clinician and access health monitoring, including blood pressure and other health indicators. The model also gives patients without reliable home broadband a way to access virtual care.
Additional partners can provide patient navigation and the secure digital infrastructure needed to make it work. For the health system, the partnership extends its reach without the capital and staffing required for another clinical site, while potentially creating a lower-cost way to support preventive and chronic care. For the bank, it provides a community service and a potential use for existing branch infrastructure. Most importantly, for patients, it turns a place they already know into a connection point for care.
That is the potential of the node: use existing community infrastructure to bring access closer to the patient rather than requiring the patient to travel to the infrastructure.