These days, Medina County is a tough place for a community hospital to operate alone.

The county's only remaining independent hospital is pushing forward with plans to expand its emergency department and make other improvements to serve one of the state's fastest-growing regions.

But with bigger health systems rushing into the county, Medina General Hospital might not go it alone much longer.

Medina General's leaders are continuing to evaluate partnership opportunities after a proposed affiliation deal with Cleveland-based University Hospitals didn't pan out earlier this year.

A deal of some type likely will happen in the future for the hospital to thrive long-term, Medina General President and Chief Executive Gary Hallman said.

Medina County's other community hospitals already have picked bigger partners.

Wadsworth-Rittman Hospital in eastern Medina County is in the process of being acquired by Summa Health System of Akron. Lodi Community Hospital in southern Medina County is owned by Akron General Health System.

''We're pushing back at this point in time and looking at the environment, the horizon, and figuring out the best thing for Medina General Hospital and the communities we serve,'' Hallman said.

Partnerships with bigger health systems can bring benefits to smaller hospitals by boosting revenues, lowering expenses through group purchasing and providing big-name recognition with consumers, Hallman said.

''Right now, we're trying to assess the proper direction and what that means,'' he said. '' . . . The main thing we're trying to do is keep the pulse of the community at hand so we're providing the right service for the public.''

In the meantime, Medina General plans to spend more than $33 million to replace its existing 19-bed emergency room with a new 39-bed E.R., as well as constructing a 30-bed inpatient unit with all single-bed rooms.

The project originally was approved by the city in 2006 but the plans have been been on hold because of a dispute over a zoning change that's needed for the addition.

A public hearing is scheduled for June 23 on the zoning change request, which Medina Planning Department Director Greg Hannan is recommending for approval.

Medina General serves about 32,000 E.R. patients each year. With the addition, the hospital will be able to accommodate about 50,000 annually.

On busy days when all the rooms are filled, patients now are cared for in several extra beds in the E.R.'s hallway.

''What we want to be able to do is provide that emergency care close to home for people in the community,'' hospital spokeswoman Robin Louis said.

The timing of the E.R. project could be crucial.

Akron General and Akron Children's Hospital announced plans last month to build an $8.6 million, 24-hour emergency department attached to the Akron General Health & Wellness Center-West, about 10 miles east of Medina General in Bath Township.

Likewise, Summa announced earlier this year that it's partnering with Medina-area doctors to build an outpatient medical complex and surgery center about a mile away from Medina General.

But, Summa spokesman Mike Bernstein said, ''We remain open to any discussion with Medina General Hospital that has the potential of benefiting the community.''

This month, UH-affiliate Southwest General Health Center is opening its new Brunswick Medical Center, with an urgent-care center, testing services and doctors' offices.

The Cleveland Clinic also has its Brunswick Family Health Center, which provides family medicine, pediatrics, cardiology, optometry, physical therapy and sports health services.

Medina County's population increased more than 12 percent from 151,095 in 2000 to 169,832 in 2007, according to U.S. Census estimates. By contrast, Summit County's overall population grew less than 1 percent during that period, and Cuyahoga County's dropped 7 percent.

The median household income in Medina County is $59,457, compared to $44,030 in Summit County, $40,547 in Cuyahoga County and $43,371 statewide, according to U.S. Census estimates.

''Medina County is an attractive place to service, so the competitors are certainly looking at that,'' Hallman said.

But when bigger hospitals move into a community hospital's service area to compete for patients rather than wait for referrals, the smaller hospital risks losing business in profitable service lines, such as outpatient surgeries, Hallman said.

Hospitals rely on profits from some areas to offset the losses in other areas, including charity care, he said.

The community hospital lost money the past two years, but revenues are exceeding expenses so far this year, Hallman said.

''You need to have all the services in balance in order to keep the hospital healthy,'' he said. ''The more those services get peeled away by competition, then it's hard to remain a healthy, viable institution.''

Community hospitals in competitive markets can succeed if they capitalize on strong local ties and provide unique services, said Tom Campanella, director of the health care MBA program at Baldwin-Wallace College in Berea.

''An advantage of a community hospital is it's tied to the community,'' he said. ''Medina General has been there for a long time. Part of the opportunity they have is to collaborate with local businesses.''

That's the approach Medina General is taking.

If the E.R. project gets approved, subsequent plans call for converting the rest of the hospital's rooms to single-bed units and turning the current emergency department into space for the hospital's growing occupational health program, called On The Clock Care.

The program provides services such as preventive education, occupational testing, injury treatment, physical rehabilitation and consulting services for local businesses.

About 13,000 to 15,000 people get services from On The Clock Care each year, Hallman said.

''Health care should be a local service,'' Hallman said, ''and that's what we're trying to provide.''