The nation's health care systems are in transition. And while hospitals across the country are grappling with changes to payment systems and quality measures, the tiniest hospitals in rural areas must work even harder to keep up.

In Iowa, the rural health care system is made up of 82 Critical Access Hospitals a special Medicare designation for smaller 25-bed facilities and 142 rural health clinics, making it one of the largest rural health systems in the country, said Gloria Vermie, director of the State Office of Rural Health Director, which is part of the Iowa Department of Public Health.

These facilities care for the more than 1.4 million people or about 46 percent of the state's population living in a rural community and are vital economic drivers in the communities they serve.

But planning their futures whether that be attracting physicians, fundraising or dealing with aging infrastructure can be a challenge.

Iowa has some of the best rural hospitals and clinics in the nation, Vermie said Improving access to quality, whole-person health care while ensuring organizations and health care professionals stay on course with state and federal changes requires vigilant dedication.

As health care evolves, small hospitals don't want to be left behind, said Kirk Norris, Iowa Hospital Association president and chief executive officer.

Shifting focus to increase the quality of care could benefit small hospitals, he said, because, with fewer patients, they frequently can respond quickly to problems areas. But at the same time, because there are limitations on how long Critical Access Hospitals can keep patients, he noted some quality measure such as infection rates really can't be applied to them.

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Surviving small: rural healthcare in Iowa