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RS3 – Rural Montana Surgical Support System

  • Need: Providing more in-state surgical care options for Montana patients.
  • Intervention: A system to keep surgical procedures in Critical Access Hospitals or provide seamless engagement of Montana's available advanced surgical expertise when needed.
  • Results: Increased surgical care options, with a side benefit of recruiting young surgeons to rural/frontier Montana.


Front Entrance of Kalispell Regional Medical Center Distance, topography and weather impacts healthcare for Montana's 1 million people residing in a 150,000 square mile area. Uniquely rural, uniquely frontier, and with nearly 50 Critical Access Hospitals (CAHs), Montana providers understand these issues inherent to the state's healthcare delivery efforts. First, and again, both the land mass and weather are factors that highlight the importance of having medical and surgical providers in the smaller, more rural/frontier areas. Second, Montana patients and their providers want healthcare as close to home as possible.

Kalispell Regional Healthcare has core values and a vision to provide all Montana patients with an in-state choice for their healthcare. One of the organization's programs specifically fulfilling that vision is their Montana Rural Surgery Support System, or RS3. Organized by Kalispell Regional Healthcare Surgical Specialists (KRHSS) at Kalispell Regional Medical Center (KRMC), the program creates collaborative relationships with their more rural/frontier surgical colleagues. The program offers surgical expertise in the smaller communities if needed and provides seamless transitions when higher levels of care are required.

The surgical team, with the support of their organization's administrators, believes this collaborative program is an alternative to the "outreach care" model, a model which often siphons revenue lines from CAHs and small rural facilities.

Services offered

The program supports rural/frontier surgeons by having a simple referral system offering solutions to three common surgical situations:

Kalispell Regional Healthcare Surgical Specialists logo

Scenario 1 – Local Operative Assistance/currently the most common program scenario:

A patient requiring an elective surgical intervention requests local care, but has a medical comorbidity that raises a potential technical challenge that might require an "extra set" of surgical hands.

RS3 solution: At the request of the local surgeon, the KRHSS surgeon travels to that facility and provides on-site assistance.

This RS3 effort results in 3 collaborative benefits:
  • Patient-centered primary benefit:
    • Patient stays locally and benefits from presence and caregiving of family and friends
  • Secondary benefits:
    • Rural/remote surgeon operates locally
    • Surgical revenue remains at the CAH
Kalispell surgeon in operating room

Scenario 2 – Local Plus Tertiary/​Quaternary Surgical Intervention in Kalispell:

Patient requires more complicated operative intervention and referring surgeon desires to do the case at KRMC.

RS3 Solution: 72-hour KRMC courtesy privileges are granted, both the referring and KRHSS surgeon operate, with the referring surgeon able to help with postoperative care.

Scenario 3 – Assumption of post-operative care

Patient requires complex primary surgical intervention, but has post-operative care needs that can be met at the more rural/frontier hospital. (Examples: pancreatectomy, rectal surgeries)

RS3 Solution: KRHSS team performs the operation. When post-operative care is appropriate for the patient's home facility, the patient returns to the referring surgeon and to their family and friends.


As of October 2017, the program is still in its infancy. Though successes have been demonstrated and local surgical collaboration is frequently happening at the smaller hospitals, early case number statistics are not available. The program has also sponsored visiting surgical residents and several have located to rural Montana. Recruitment then becomes another clear benefit of the RS3 program.

Additionally, in recent months the RS3 program has been contacted by surgical professional organizations as well as surgical training programs to explore how the high-volume RS3 program can become more formalized as a way to address training options to meet global health/rural surgical care needs.


Practice coverage for the rural/frontier surgeon who wants to be with their patient requiring a higher level surgical intervention (Scenario 2 under services).


The following factors are suggested for replication in another state:

Kalispell surgical team in operating theater
  • Enough surgeons with the same vision to engage in the coordinated effort
  • Implementation of a "just say 'yes'" policy: full and immediate support of the referring surgeon requesting help, no matter the comorbidities, payer source or surgical complexity
  • Administrative support that:
    • Views surgical relationships with smaller hospitals as a valuable/financially sustainable relationship
    • Has a similar core value and vision to Kalispell Regional Healthcare: offer options to keep care in the home state
  • Establish a relationship with surgical training programs, especially with an eye towards the American College of Surgery's Transition to Practice program

Contact Information

David Sheldon, M.D., Kalispell Regional Healthcare Surgical Specialists
Kalispell Regional Healthcare

Critical Access Hospitals
Frontier and remote areas
Recruitment and retention of health professionals

States served

Date added
November 1, 2017

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.