Housing Challenges and Opportunities for Rural Residency Development

The ongoing expansion of rural residency programs is essential to addressing the physician shortage in the rural United States. Evidence shows that exposure to rural residency, and potentially positive lived experience in a rural community, increases the likelihood of physicians entering rural practice.^1-3  However, a substantial barrier for such programs is finding sufficient housing for residents. While most graduate medical education (GME) training in the United States occurs in urban areas, rural health systems are increasingly taking advantage of federal and state initiatives to start new rural-based residency programs.^4-8  The number and size of these programs, which seek to “grow their own” and “train and retain,” has rapidly expanded, but housing has not kept pace.^9-11  Rural communities often have less available housing than urban communities. Rural housing is more likely to be owned (81%) than urban housing (60%), leading to a smaller rental market.¹²  Residents in all communities—regardless of rurality and housing inventory—need access to safe, secure, affordable, and good-quality housing that is convenient to the workplace.

Rural residency programs, where trainees spend more than 50% of their training in a rural location, face housing challenges that differ from those of residents on rural rotations. For residents starting training in the community and looking to purchase a home, the short time frame from the Match to the start of residency may be a challenge in the generally more slowly moving rural real estate market. Family medicine rural track programs in the prototypical “1 + 2 format,” where residents spend postgraduate year (PGY) 1 in an urban location with PGY-2 and PGY-3 in a rural site, have an advantage on the front end (more time to look for a rural home), but may have a financial disadvantage in owning a home for only 2 years. Longer-term rentals in rural communities that lack nearby universities or colleges may be hard to come by.

Rural rotations present a different challenge and require creative solutions. For example, PGY-1 residents who spend their first year living in an urban location may have continuity clinic at their rural site 60 miles away, requiring weekly 1-night housing options. Programs often require subspecialty rotations in distant urban locations to meet certain Accreditation Council for Graduate Medical Education requirements, requiring short-term housing in the urban location.

Solutions to housing for rural GME are as diverse as rural GME itself. Local hospitals, teaching health centers, academic health centers, institutions of higher education, Area Health Education Centers, state offices of rural health, local foundations, Veterans Affairs, community chambers of commerce, and regional banks can all play roles as partners (or investors) in identifying housing solutions with local GME leadership. As part of our evaluation of new rural programs launching from the Health Resources and Services Administration (HRSA) funded Rural Residency Planning and Development grants, we conducted interviews with 25 of those in grantees’ leadership to learn how they are addressing residents’ housing and travel needs. After conducting a thematic content analysis of the transcripts, we found a variety of creative solutions ranging from short- to long-term rentals, housing and travel stipends, rehabbing housing units, and new construction (online supplementary data). Rural residency programs can also help by connecting residents to realtors, quickly securing long-term rentals shortly after the Match, offering place-based stipends for residents living within city limits, purchasing a house in partnership with a local foundation, or even building a row of townhouses near the hospital. In some cases, housing may best be located between clinical sites to minimize commuting.

For away rotations, residency programs may use short- or long-stay hotels and short-term rentals (eg, Airbnb). Programs often provide housing or stipends for housing and travel to support rotations more than 60 miles from the primary clinical site. Rural health facilities may consider investing in aggregate short-term housing, which could include housing for temporary nurses, attending physicians, and other professionals. Medical schools that are creating short-term (ie, 2-6 weeks) rural rotations for undergraduate medical education may be helpful partners.

Buying, improving, developing, and maintaining real estate is expensive. It is best done in consultation with professionals who have expertise in real estate, development, rural investment, and financing. Housing is often financed by a “capital stack”—a combination of loans and equity secured for the purchase of and/or development of a property. Typically, at the bottom of the capital stack is the preferred lender, often a bank, which is then supported by other lenders with lower expectations of return on investment. Other common holders of debt or contributors of equity, often with smaller portions and decreasing preference in the capital stack, can include subordinate debt, government equity, grant equity, owner/developer equity, and local program equity. A real estate project and many lending programs might require a down payment (eg, 20%) that can come from grant equity (eg, local philanthropy), owner/developer equity (eg, a hospital), or local program equity (eg, GME program).

As GME programs strategize about resident housing, they may seek to connect with development experts early for advice. Two important sources of expertise at early program development stages are the US Department of Agriculture and Community Development Financial Institutions (Table). Many organizations at the local and state levels can assist with program development needs, including Community Development Corporations and Economic Development Partnerships (EDPs). The Appalachian Regional Commission is an important EDP and makes investments in rural development in the 13 states and 432 counties that make up Appalachia.¹⁷  Finally, state offices of commerce can be important sources of information and funding for initiatives, including infrastructure, building renovation, and site development.

Rural GME programs have unique housing needs that must be met with creativity and partnerships. Much of what we can learn from approaches to rural GME housing may have applications across other parts of medical education, such as housing for students. A clear understanding of a particular area’s needs and stakeholders is essential. Each program’s approach to raising capital is similar, though the programs and investors may vary. With good housing, prospective candidates may be more likely to accept rural residency positions, and residents may be more likely to live and work in rural communities for the long term.

The online supplementary data contains solutions used to address housing and travel for rural residency programs.

Disclaimer: The Rural Residency Planning and Development Program–Technical Assistance Center (RRPD-TAC) is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under cooperative agreement #UK6RH32513. The Teaching Health Center Planning and Development Program-Technical Assistance Center (THCPD-TAC) is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under cooperative agreement #U3LHP45321. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government.