For nearly half a century, the Mountaintop Area Medical Center had been a cornerstone of the community of Snow Shoe, Pa., about 30 miles north of State College. From this small and unassuming red brick building, a lean team of clinicians provided everything from primary care to family planning and immunization services to the 1,700 residents who call this rural Pennsylvania town home. If you lived in Snow Shoe and needed any sort of medical attention, Mountaintop was the place to go.

But in July 2021, just a few months shy of the clinic’s 50th anniversary, Mountaintop sent a letter to local residents informing them that it would be shutting down by the end of the summer. The number of patients visiting the facility had been in a steep decline for years, and in its final months the clinic had been staffed by just three employees, two of whom had to commute up to 90 minutes each way to reach the clinic. When both of those employees quit, the center had no choice but to shut down.

Mountaintop’s closure was a grim capstone on a string of essential businesses that had left Snow Shoe over the preceding two years, including the town’s only pharmacy and only full-service grocer. For residents, this means that accessing basic primary care services now requires at least a 30-minute drive on winding mountain roads to clinics in Philipsburg, Bellefonte, or State College. And for the many members of Snow Shoe’s community who are elderly or lack reliable transportation, this is effectively the same as having no access to medical facilities at all.

When Michael McShane ’09 Sci, ’14 MD Medicine, an associate professor in the Penn State College of Medicine, heard about what was happening in Snow Shoe, he saw a community on the verge of a serious health crisis—and an opportunity for Penn State to make a meaningful difference. Since many of Snow Shoe’s residents couldn’t travel to a clinic, McShane hatched a plan to bring a clinic to them.

In 2022, he and a small group of Penn State students and faculty launched the LION Mobile Clinic in a rented RV that they drove to Snow Shoe and other rural communities around State College. Depending on the day, residents could stop by the mobile clinic (later upgraded to an Airstream trailer) to get COVID-19 tests, flu shots, blood pressure screenings, and a variety of other medical services. Inside, the trailer functions as a versatile medical space with an exam table and standard medical equipment that can be adapted to the needs of a particular community. But the clinic’s impact extends far beyond traditional medical services.

“Health care access is only about 20% of a patient’s overall health and well-being; the other 80% is their behavior, physical environment, food access, financial stability, and education,” says McShane. “These are people living in locations that are close to being uninhabitable, and you’re not going to care about a colon cancer screening if you can’t afford food or gas to heat your home. So we’re trying to build this mobile operation to help confront these other health concerns.”

McShane points to an example from the early days of the LION Mobile Clinic, when he and his team made a house call to an elderly woman living in rural Pennsylvania after spending the day administering flu shots at a nearby senior center. Although the woman was less than a tenth of a mile from the senior center, she hadn’t been able to make the journey to the facility to get her shot. When McShane and his team arrived at her home, they quickly realized why: The stairs of her house were covered in a thick blanket of ice that prevented the woman, who had recently broken her hip, from safely leaving her home. As McShane soon learned, she wasn’t even able to reach her attic, where she had stored her winter coat. She was trapped in her own home and unable to access basic health care services like a free flu shot right down the road. 

In the time since, McShane says, the clinic team has made house calls to deliver groceries to her and do small maintenance jobs, such as fixing her air conditioning during a heat advisory. “We call it tailgate medicine,” says McShane. “We drop the tailgate of our truck, open the trunk, and deliver whatever care we can.”

By any measure, the initiative has been a resounding success. In just a few years, the LION Mobile Clinic has treated over 3,000 rural community members, and the program recently purchased a second Airstream, which it will use to expand its coverage across rural Pennsylvania. Calling it “an incredible example of where our commitment to public impact and student success meet,” Penn State President Neeli Bendapudi praised the mobile clinic last year as “an innovative model for teaching and research that empowers our students—future health care providers—to build connections and gain real experience within Pennsylvania communities.”

A rolling health clinic in a converted camper may be an unorthodox approach to delivering medical care, but challenges as big and as urgent as those inherent in rural health demand creative solutions.

The story of Snow Shoe is emblematic of an acute and sustained health crisis unfolding across rural America, where primary care physicians are becoming an endangered species and essential health services are disappearing entirely from rural communities. There are many factors contributing to this crisis in the United States, including an aging physician workforce, economic pressures on rural hospitals that serve high numbers of Medicare and Medicaid patients, and the challenge of attracting new providers to isolated communities with limited resources.

“When it comes to rural health, your ZIP code is a bigger predictor of health than your genetic code,” says Karen Kim, dean of the Penn State College of Medicine. The simple fact is that rural populations see higher rates of smoking, substance abuse, and deaths from preventable cancers and other chronic diseases compared to people living in urban and suburban areas. Among the array of factors that influence rural health outcomes, lack of both care facilities and timely access to clinicians are prominent.

Geographic isolation compounds these challenges. In many rural Pennsylvania counties, residents must travel long distances to reach specialized care such as trauma centers or obstetrics services. These delays can be life-threatening. The Pennsylvania Department of Health has identified several rural counties as “maternity care deserts,” areas with no hospital obstetric unit or practicing obstetric providers. In some rural communities, maternal and infant mortality rates approach that seen in developing countries.

The scale of the problem is significant. Approximately one in four Pennsylvanians lives in a rural community, spread across more than 46,000 square miles. These residents face the dual burden of a large geographic footprint and widely dispersed populations. The result is not only the logistical difficulty of reaching care, but also chronic shortages of clinicians willing or able to practice in rural areas.

That geography, however, is also what makes Penn State uniquely positioned to lead. “We are the only academic health system located in rural Pennsylvania,” Kim says. “For that reason alone, we have a social and moral obligation to care for these vulnerable populations.”

Penn State maintains a presence in all 67 counties through its commonwealth campus system and agricultural extension programs. This infrastructure connects directly with partners like the Pennsylvania Office of Rural Health, which has been headquartered at Penn State since its inception in 1992. For the past three decades, the office has been under the direction of Lisa Davis and has served as the state’s primary source of coordination, technical assistance, and networking for rural health care delivery in the state. Davis ’94 MHA H&HD and her colleagues work with hospitals, primary care clinics, training programs, community organizations across the state, and more, providing everything from continuing education to policy advocacy at the state and federal levels. Through the Penn State Worker Protection Standard Program, the office assists agricultural producers on the safe use and storage of pesticides. The office fulfills more than 1,000 technical assistance requests annually.

The expertise and network of relationships with Pennsylvania communities through the Office of Rural Health and other programs provides the foundation for the College of Medicine to address rural health systematically rather than sporadically. Since taking the helm of the College of Medicine as dean in September 2023, Kim has organized the college’s rural health efforts around five interconnected pillars: community engagement, research, policy advocacy, clinical care, and training the next generation of providers.

The comprehensive approach leverages Penn State’s full range of expertise while acknowledging that sustainable change requires long-term partnerships rather than short-term interventions. But even with the university’s extensive resources and commitment, the fundamental challenge that has plagued rural health for decades persists: There simply aren’t enough clinicians practicing in rural counties.

“As those people retire, there are no people coming in after them,” Davis says. “When I started in rural health, the No. 1 issue was the workforce. Thirty-one years later, the No. 1 issue is still the workforce.”

When Ben Fredrick ’00 MD Medicine assumed the directorship of Pennsylvania’s Area Health Education Center (AHEC) in 2022, half of the state’s rural counties had already lost at least 10% of their primary care workforce over the previous decade, and some counties had lost more than a third of their physicians. The shortage of primary care physicians practicing in many rural areas will get worse before it gets better: In Susquehanna County, for example, half of all primary care physicians are already 65 or older, and similar demographic patterns exist across rural Pennsylvania. Meanwhile, a 2021 report from the Pennsylvania legislature found that only 3% of medical school graduates enter rural primary care, creating a pipeline problem that would require quadrupling the number of students applying to medical school just to reach parity with urban areas.

There is a growing body of research that points to two main factors that determine whether a medical student ends up practicing in a rural area. The first and most significant is the student’s background. People from rural communities are far more likely to return to rural practice, with about two-thirds of rural students who enter medicine eventually practicing in rural areas.

The challenge is that rural students remain dramatically underrepresented in medical school admissions. They often lack access to test preparation resources, have fewer opportunities for the research experiences and extracurricular activities that medical schools prize, and may come from families with no experience navigating the complex medical school application process.

Two years ago, AHEC—a program office based in the College of Medicine’s Department of Family and Community Medicine—launched a pilot program called the Primary Care Ambassador Program, designed to engage students with rural health before they apply to medical school. The program supports Penn State students from rural backgrounds and provides stipends, clinical shadowing experiences, and training as community health workers to not only give them a leg up when they apply to medical school, but also to expose them to the opportunities in primary care in rural communities.

“One of the primary focuses of this project has been identifying ways we can include students in parts of our research, service, or education mission,” says Fredrick. “It’s a great opportunity for them to not only help a local community, but also gain experience that will help differentiate them as they enter the next phase of their careers.”

But recruiting students into primary care in rural communities is just the beginning. The second biggest determinant of whether a physician or other health professional will enter rural health is the amount of exposure they get to rural primary care during medical school. Here, the dosage matters significantly: A brief exposure during medical school isn’t sufficient, and students should ideally spend a minimum of 12 to 20 weeks over the course of their medical education to increase the likelihood of engaging in rural practice when they graduate.

At Penn State, AHEC addresses this through its Community Oriented Rural Education (CORE) program, which requires medical students to spend at least eight weeks in rural Pennsylvania during their training. AHEC serves as a matchmaking service between students and rural clinicians known as preceptors, who will teach the students in their clinic. During their CORE rotations, students spend about 80% of their time in clinical settings and 20% of their time engaging with the broader community, whether that’s accompanying nurses on home visits, participating in mobile clinics, or volunteering at a food bank. This community immersion helps students understand not just the clinical aspects of rural medicine, but the social, economic, and cultural factors that shape rural health outcomes.

“Our hope is that when they’re on this CORE rotation, they’re getting to know the community and hopefully falling in love with the community,” says Fredrick. “It’s all about recruiting the right kinds of individuals out into rural Pennsylvania.”

In 2023, nearly 4,000 Pennsylvanians died from opioid-related drug overdoses. While this is a tragedy that affects all communities, residents of rural areas are nearly twice as at risk of an overdose death as residents of cities. For primary care physicians working in these communities, treating patients with addiction has become a daily reality, yet many lack the training to provide the most effective interventions.

“When I trained in medical school, we didn’t have medication-assisted treatment for opioid use disorder,” says Jennifer Kraschnewski, a professor of medicine and director of Penn State’s Clinical and Translational Science Institute (CTSI). But today, there are many evidence-based treatments available to help people struggling with addiction, and local health care providers are generally in the best position to administer them. The challenge, says Kraschnewski, is accessing specialized training needed to provide the most effective care.

“We know that primary care doctors in the community have a lot to do, especially in rural areas,” says Kraschnewski. “They are often the closest person for care, but have to refer their patients to specialists who may be hours away so they can get the care they need. The question was: How do we take the expertise from our academic medical center and help upskill rural primary care doctors so they can care for patients closer to home?”

The answer is Project ECHO, a tele-mentorship program within CTSI that connects rural physicians with addiction specialists and other experts at Penn State’s academic medical center. Rather than requiring patients to travel hours for specialty care, Project ECHO brings the expertise directly to rural providers through virtual learning communities that meet regularly to discuss challenging cases and share best practices.

Unlike most continuing education programs, Project ECHO is designed to have immediate practical application for clinicians. Rural primary care doctors bring de-identified patient cases to sessions with academic specialists and other rural care providers. During the sessions, clinicians receive real-time guidance on cases they’re seeing in their clinic that can range from pregnancy complications to liver disease.

“By providing this education for the latest and greatest evidence-based care to rural primary care doctors, we’re helping them provide care for their patients closer to home at the first or second line of treatment,” Kraschnewski says. In addition to addiction medicine, Project ECHO has proven valuable for conditions such as orthopedic injuries, mental health, and women’s health issues, which are among the most common types of cases seen by rural physicians. Through Project ECHO, these physicians are able to gain the latest evidence they need to make treatment decisions with confidence, and potentially save patients from making expensive and perhaps unnecessary trips to specialists while ensuring a high standard of care. 

Beyond clinical skills, Project ECHO addresses a less visible but equally important challenge: the toll that isolation takes on doctors practicing in rural communities. Rural physicians often work without nearby colleagues to consult, making clinical decisions in isolation that urban physicians might discuss easily with specialists down the hall. By creating learning communities, Project ECHO helps rural providers develop relationships with both academic experts and rural colleagues facing similar challenges, creating ongoing resources they can access beyond formal sessions.

“It’s a challenge being a sole provider at a clinic,” says Kraschnewski. “Anything we can do to help with the retention of these folks so they’re there to care for their communities is important.”

Schuylkill County is a former coal mining region in eastern Pennsylvania that is home to nearly 150,000 people and has the dubious distinction of having some of the worst health outcomes out of any of the state’s 67 counties. Decades of economic decline have led to high rates of chronic disease and substance abuse, which have only been exacerbated by increasingly limited access to health care services. A primary example of everything that can go wrong in rural health, it’s also at the forefront of new approaches to community-led research programs that may hold the key to turning things around.

In May 2024, more than 100 hospital administrators, community leaders, and Penn State faculty and students gathered at Penn State Schuylkill for the fourth Community-Driven Research Day. This wasn’t a typical academic medical conference where researchers convene to present the latest findings in dry, closed-door sessions. Instead, the researchers were there to listen to the community and learn more about their most pressing health challenges so they could work together to develop research-based solutions.

“Research takes a lot of different forms,” says Kraschnewski, who helped organize the Schuylkill County event. “We already have a lot of medications, treatments, and interventions. What’s missing is the last mile: how to take those solutions, adapt them to a specific community, and implement them.”

Penn State’s Community-Driven Research Days began in 2019 and represent a fundamental departure from how academic institutions typically engage with rural communities on matters of health. In the traditional model, university researchers identify problems through data analysis, design studies around those problems, and then attempt to recruit community members to participate in their research. The academic institution drives the agenda, determines the priorities, and controls the research questions. Communities become subjects to be studied rather than partners in identifying solutions.

The community-driven approach reverses that dynamic. Local organizations set the agenda by identifying their community’s most urgent health challenges through data presented to them by university researchers. University researchers then work with local leaders to match community priorities with appropriate expertise and evidence-based solutions. “Rather than asking the community to participate in our research, we’re participating in the community’s research,” says Fornessa T. Randal, inaugural director of the College of Medicine’s Center for Advancing Health Equity in Rural and Underserved Communities (CAHE-RUC). “Having strong partners in community-based participatory research can help communities identify pressing needs.”

For Randal, a key insight from rural health care studies is the critical need to empower and extend the reach of existing community infrastructure rather than trying to replace it. Churches, rotary clubs, rural health clinics, and other non-medical community organizations are embedded in their communities and working with their constituents every day; when they’re armed with the data-driven and qualitative knowledge and resources, they become ideal partners for sustainable health interventions that benefit the community and researchers alike.

Since July, CAHE-RUC has worked with the Penn State Cancer Institute, Penn State Health, and other medical faculty, including dermatology professor Charlene Lam, on pop-up clinics—sometimes in collaboration with the LION Mobile Clinic—in rural communities. Within a few events in targeted rural communities, more than 100 people were screened, with nearly 30% needing referrals for follow-ups including biopsies or pre-cancerous surgical removals. This integration represents the center’s commitment to meeting communities where they are, both geographically and in terms of their own priorities and capabilities. It’s an approach that  recognizes that sustainable change comes from addressing needs at the local level.

The health care challenges facing Snow Shoe and other rural communities across Pennsylvania aren’t unique. What Penn State experts are hoping sets the commonwealth apart is how it’s responding to these challenges.

The university’s distributed campus system, agricultural extension programs, and research capabilities offer unique opportunities to address rural challenges comprehensively rather than in a piecemeal fashion. Project ECHO connects rural physicians with academic specialists. The LION Mobile Clinic brings care directly to communities. CAHE-RUC ensures that research priorities align with community-identified needs. AHEC builds the workforce pipeline that rural areas desperately need.

America’s rural populations are the foundation of the nation’s food system, manufacturing base, and energy production. The farmers, factory workers, and small business owners who keep rural communities running also sustain urban and suburban life in countless ways. When rural communities struggle with health disparities, workforce shortages, and economic decline, the effects ripple outward to affect everyone. The future of rural health care will require recognizing that it is not a niche concern, but a fundamental component of all of our well-being.