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Rural HealthResearch In Progress in the Rural Health Research Centers Program

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Rural Health Research In Progress ■ iii

Rural HealthResearch In Progress in the Rural Health Research Centers Program

Ninth Edition

February 2005

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Acknowledgments and Credits

Rural Health Research in Progress is produced annually by theMaine Rural Health Research Center with support from the FederalOffice of Rural Health Policy. We greatly appreciate the cooperationof the other rural health research and policy analysis centers and theguidance of our project officer, Joan Van Nostrand.

■ Karen B. Pearson, Editor■ Christine Richards, Richards Design and Production

Database for Rural HealthResearch in Progress

http://www.rural-health.org/database

Information about current rural health services research conductedby the Rural Health Research Centers Program of the Federal Officeof Rural Health Policy (ORHP) and many other investigators isavailable on the internet. The Maine Rural Health Research Centerat the University of Southern Maine receives funding from ORHP tomaintain a searchable database of rural health services research andpolicy analysis in progress. This database includes all ORHP-fundedstudies, as well as research funded by other federal agencies, majorprivate foundations and other sources.

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© February 2005

Rural Health Research In Progress ■ v

This book describes the research and policy analysis projects underway in the Rural HealthResearch Centers Program of the Federal Office of Rural Health Policy (ORHP), HealthResources and Services Administration, U.S. Department of Health and Human Services.The objective of this program is to produce research and policy analyses that will be usefulin the development of national and state policies to assure access to quality physical andbehavioral health services for rural Americans.

The individual grantees and the eight research and policy analysis centers currently fundedin part or in whole by the Federal Office of Rural Health Policy are addressing a wide rangeof problems in the financing, organization and delivery of rural health care, including:

Behavioral HealthBioterrorism PreparednessDefining RuralEmergency Medical Services (EMS)Health Insurance and the UninsuredHealth PromotionHospitalsHospitals: Rural Hospital Flexibility ProgramLong Term CareMedicaid and S-CHIPMedicarePublic HealthQualityRacial and Ethnic PopulationsResearch-Policy InterfaceService DeliverySpecial Needs of Women and ChildrenState-level DataWorkforce

This ninth edition summarizes the Rural Health Research Centers’ current research in theseareas and provides an anticipated completion date for each project. Descriptions of theCenters and lists of their current publications are located in the last section of thispublication.

For additional information on the Rural Health Research Center Program, please contactJoan Van Nostrand at 301-443-0835 or visit the ORHP website at http://ruralhealth.hrsa.gov

Office of Rural Health PolicyParklawn Building Room 9A-555600 Fishers LaneRockville, MD 20857

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Rural Health Research In Progress ■ vii

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: Part 1 ■ Current Projects

The projects are grouped by topic. Abstracts include the purposeand methodology of the project along with its policy relevance andany anticipated publications. Contact information is provided foreach project.

Behavioral Health �� Bioterrorism Preparedness �� Defining Rural �� Emergency Medical Services (EMS) �� Health Insurance and the Uninsured �� Health Promotion �� Hospitals �� Hospitals: Rural Hospital Flexibility Program �� Long Term Care �� Medicaid and S�CHIP ��Medicare �� Public Health �� Quality ��Racial and Ethnic Populations �� Research�Policy Interface �� Service Delivery �� Special Needs of Women and Children �� State�level Data �� Workforce ��

Part 2 ■ Center Descriptions and Publications ��

Part 3 ■ Indexes

Alphabetical List of Projects�� List of Projects by Center �� List of Projects by Funding Source ��

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Behavioral Health ■ �

Assessing Demand and Capacity forBehavioral Health Services in Northern Minnesota

University of Minnesota Rural Health Research CenterExpected completion date: December 2004

Principal Investigator: Donna D. McAlpine, Ph.D., 612-625-9919 or [email protected]: Generation Health Care Initiatives

VBehavioral HealthPart 1: Current Projects

Challenges to delivering mental healthservices in Northern Minnesota mirrorthose experienced in rural settingsthroughout the nation. Yet, little isknown about how services can best beorganized to meet these challenges.This project gathered the informationnecessary to measure demand andcapacity and develop policy recom-mendations to improve the organizationof behavioral health services in NorthernMinnesota. The project has three centralobjectives:■ Assess demand and capacity for

behavioral health services

■ Develop a model to monitordemand/capacity over time

■ Propose recommendations to improvethe organization of behavioral healthservices.

The project included key informantinterviews and the collection of primarydata over a one-year period from organi-zations and providers who serve personswith mental health care needs in the region.The data will be used as input to a modelthat will be developed to forecast thebalance of demand and capacity for mentalhealth services over time.

Differential Effectiveness of Enhanced Depression Treatment forRural and Urban Primary Care Patients

WICHE Rural Mental Health Research CenterExpected completion date: September 2005

Principal Investigator: Kathryn Rost, Ph.D., 303-221-3904, or [email protected]: Federal Office of Rural Health Policy, HRSA

achieve outcomes with interventioncomparable to their urban counterparts,and whether differences are explained bytreatment mediators (e.g., evidence-basedcare) or psychosocial mediators (e.g.,stressful life events and social support).This project will test pre-specifiedhypotheses by conducting secondaryanalyses of an RCT known as the QualityEnhancement for Strategic Teaming(QuEST) study, consisting of a

Rural primary care practices encountergreater challenges than their urbancounterparts when they try to improvethe quality of care their depressedpatients receive. Rather than assume that“one size fits all,” investigators need toevaluate whether depression treatmentquality intervention has comparableeffectiveness in improving outcomes inrural and urban patients. This project willexplore whether rural populations

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consecutively sampled cohort of 479depressed primary care patients recruitedfrom 12 practices in 10 states (Colorado,Michigan, Minnesota, New Jersey, NorthDakota, North Carolina, Oklahoma,Oregon, Virginia, and Wisconsin); 160 ofthese depressed primary care patients arerecruited from practices in non-MSAcounties in 4 states (Minnesota, NorthDakota, Oregon, and Wisconsin). Thestudy’s strength is its ability to extendpreliminary explorations the research

team has conducted to a definitive studyof differential intervention effectiveness,identifying mediators that explain anydifferential effects of the intervention onoutcomes. These mediators can then betargeted for intervention refinementbefore these initiatives are disseminatedto rural populations. This project willproduce a manuscript for peer-reviewedpublication, a working paper, a researchsummary, a brochure, and a conference/grand rounds presentation.

Effects of Alcohol Use on Educational Attainmentand Employment in Rural YouthSouth Carolina Rural Health Research CenterExpected completion date: August 2005Principal Investigator: Janice C. Probst, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

As they pass from teens to early adult-hood, a significant portion of Americanyouth initiate alcohol use. The rates ofalcohol use rise dramatically, from 3percent at age 12 to 49 percent at age 20.Previously, it was believed that strongsocial connections present in rural areasreduced youthful consumption of alcoholand substance abuse, but recent studiessuggest that the rural-urban gap hasclosed. Alcohol use in youth has beendemonstrated to lower educationalattainment, but little is known aboutwhether or not youthful alcohol useaffects employment opportunities andlower wages. This study proposes to

examine the effects of alcohol use duringthe teen years on subsequent educationalattainment and employment in a panel ofrural residents. If the effects of youthfulalcohol use are more severe and morelong lasting in rural areas, then programstargeting these locales should beresearched and advocated by theSubstance Abuse and Mental HealthAdministration. This study will use alongitudinal panel study design for theperiod 1979 to 1998, employing theNational Longitudinal Survey of Youth-1979 data set, which is an ongoing annualpanel survey of persons who werebetween the ages of 14 and 22 in 1979.


Estimated Mental Health Care Utilizations in Rural AreasSouth Carolina Rural Health Research Center

Expected completion date: August 2005Principal Investigator: Janice C. Probst, Ph.D., 803-251-6317 or [email protected]

Funder: Federal Office of Rural Health Policy, HRSA

This project will provide a descriptivepicture of mental health and substanceabuse treatment utilization among therural population with the emphasis onrural minorities. Rural minoritypopulations may be at a higher risk forpoor outcomes due to their vulnerabilityand lack of adequate internal resourcessuch as education and external resourcessuch as health insurance. This researchwill focus on the following types of

mental health and substance abuseutilization:■ Type of mental health and/or

substance abuse treatment received■ Setting of treatment received

(e.g., office based)■ Receipt of prescription drugs for

mental health and/or substanceabuse treatment.

Identifying At-Risk Rural Areas For TargetingEnhanced Depression Treatment

WICHE Rural Mental Health Research CenterExpected completion date: December 2005

Principal Investigator: John C. Fortney, Ph.D., 501-257-1726 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will identify rural areas thatshould be targeted for early adoption ofevidence-based depression treatmentsbased on community need. The goal is toprovide health plans with a scientifically-based method to identify counties ingreatest need and to inform national,regional, and local decision-makers aboutdistributing scarce resources to areaswhich would most benefit from enhanceddepression treatment. The results of thisresearch will benefit health plans thatcover these communities, particularly ifadoption of evidence-based depressiontreatments can reduce the elevated ratesof hospitalization observed in depressedrural residents. The rate of depression-related hospitalizations is the bestnationally available proxy for apopulation’s need for enhanced

depression care programs.Project staff will conduct a

secondary database analysis of theStatewide Inpatient Database (SID),containing the universe of hospitaldischarge records from all communityhospitals in participating states. De-identified hospitalization data will also becollected from other national databasessuch as claims records from managedbehavioral health plans (i.e., carve-outs)as well as encounter data from theDepartment of Veterans Affairs. Inaddition, the project will investigate thedegree to which geographic areas at riskfor depression-related hospitalizationscan be predicted by rurality, economicfactors, access to care, and demographics.Although prevalence rates have not beenfound to differ across rural and urban

■ Rural Health Research In Progress

areas, it is expected that rurality isassociated with hospitalization rates dueto a number of reasons including pooraccess to outpatient specialty care andpoor economic conditions. Incombination with small area variationanalysis methodologies, a GeographicInformation System (GIS) will be used toexamine spatial variation in need acrossgeographically defined populations andto identify geographic areas of high risk.Specifically, the GIS will be used tospatially reference data from varioussources and geographically join layers of

spatially referenced information to createcommunity health profiles.

Two papers will be generated fromthis project. The first paper will describecommunity-level risk factors fordepression-related hospitalizations. Thesecond paper will identify those countiesin the U.S. were residents at the highestrisk for a depression-relatedhospitalization. Future research projectswill focus on developing strategies toimplement evidence-based care fordepression in these high riskcommunities.

The Impact of Mental and Emotional Stress onRural Employment PatternsMaine Rural Health Research CenterExpected completion date: September 2005Principal Investigator: Lisa Morris, Ph.D., 207-780-5876 or [email protected] Person: Stephenie Loux, M.S., 207-780-5774 or [email protected]: Federal Office of Rural Health Policy, HRSA

Although society provides supplementalsecurity income to individuals withserious and persistent mental illness,those with less serious emotionaldisorders or sub-acute mental distresslack eligibility for these benefits.However, poor mental health status canresult in significant negative effects on theworker, his or her family, and the localcommunity and its economy. Given thesmaller, less diversified rural economy,the lack of Employee Assistance Programsand mental health insurance benefits, andthe shortage of mental health providers,the effects of mental health problems arelikely to be exacerbated in rural areas. Inthis study, the National LongitudinalSurvey of Youth will be used toinvestigate how mental health symptomsaffect employment patterns, and theextent to which these effects differ by

rural and urban residence.Specifically, the following questions willbe addressed:■ Are there rural-urban differences in

the prevalence of mental healthproblems, ranging from clinicalconditions to sub-acute, undiagnosedmental and emotional stress amonglabor force participants/nonparticipants and employed/unemployed persons?

■ To what extent do mental andemotional symptoms and theirseverity predict lower job retentionand longer unemployment spells andare there rural-urban differences?

■ Does the impact of mental andemotional health symptoms differaccording to the type of job transition(left for another job, left for no newjob, remained in same job but at


reduced hours) and are there rural-urban differences?

Developing a better understanding ofhow mental health problems affect ruralworkers will not only assist health andhuman service providers in targetinginterventions to workers needing support,

but will also inform employers about howthey might help employees continue tofunction productively on the job. Findingsfrom this study will include a workingpaper, presentations at nationalconferences, and submission to a peer-reviewed journal.

Maine Mental Health Evidence-BasedPractice Planning Initiative

Maine Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: David Lambert, Ph.D., 207-780-4502 or [email protected]: National Institutes of Mental Health

This project was part of a one-yearplanning grant for the state of Maine’sDepartment of Behavioral andDevelopmental Services (BDS) to assessthe state’s need, capacity and readinessfor implementing evidence-basedpractices (EBP) at the community mentalhealth level. An important issue is thecapacity of implementing EBP in ruralareas, given infrastructure andtransportation challenges they face. Majorcollaborators on the planning grant are

the Muskie School, University ofSouthern Maine; Department ofPsychiatry Research, Maine MedicalCenter; and the New Hampshire-Dartmouth Psychiatric Research Center.The Muskie School’s role was to developand conduct a survey of communityproviders and BDS regional and areaofficials to assess the current knowledge,perceived need, and strategies forenhancing and implementing EBP.

Mental Health Encounters in Critical AccessHospital Emergency Rooms: A National Survey

Maine Rural Health Research CenterExpected completion date: March 2005

Principal Investigator: David Hartley, Ph.D., 207-780-4513 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will survey Emergency Room(ER) managers in a nationallyrepresentative sample of Critical AccessHospitals (CAHs) to determine theproportion of ER encounters involvingmental health pathology, types of mentalhealth problems most commonly seen inthese encounters, and resources availableto CAHs to address the problems

encountered. Project staff will alsoinvestigate whether the presence of theother two safety net provider types in thecommunity (primary care and mentalhealth), the rurality of the community (asindicated by RUCA classification), or thepresence of another hospital in the countyaffect the volume or types of mentalhealth problems encountered.


polices and examined the effect of thesevariations on the availability of mentalhealth services in rural areas. The studydesign is intended to classify states by themix of their policies on licensure,payment and coverage for mental healthservices, and to examine the effects ofthese combined policies on the avail-ability of mental health services in ruralareas. Final products will include a reportwith policy recommendations, a policybrief, and two presentations targeted atrural stakeholders and statepolicymakers.

Mental Health Services: The Effect of Variations in State PoliciesSouthwest Rural Health Research CenterExpected completion date: March 2005Principal Investigator: Catherine Hawes, Ph.D., 979-458-0081 or [email protected]: Federal Office of Rural Health Policy, HRSA

National Study of Substance Abuse Prevalence & TreatmentServices in Rural AreasMaine Rural Health Research CenterExpected completion date: August 2005Principal Investigator: David Hartley, Ph.D. M.H.A., 207-780-4513 [email protected] Person: John A. Gale, M.S., 207-228-8246 or [email protected]: Federal Office of Rural Health Policy, HRSA

Nationally, the rate of mental illness issimilar for persons living in urban andrural areas. However, the availability anduse of mental health services is worse inrural areas than urban ones. Many factorscontribute to the relatively low use ofmental health services in rural areas. Inparticular, state licensure or “scope ofpractice” acts are thought to have aprofound effect on access since thirdparty payers often base their paymentand coverage decisions on these statepolicies.

This study identified variations instate licensure and payment or coverage

Substance abuse is a major and growingthreat to the health and well-being ofrural individuals, their families, and theircommunities. It frequently co-occurs withmental and/or physical health problemsand is detrimental to effective school, job,and parenting performance and highlycorrelated with anti-social and criminalbehavior. These problems may be morepervasive in rural areas given that higherrates of substance abuse are associatedwith higher levels of poverty andunemployment and lower levels ofincome. Substance abuse strains ruralservice systems which are often

overextended and under-resourcedrelative to urban systems. The ability toorganize effective substance abusedelivery systems in rural communities ishampered by limited supplies ofspecialized providers and services, lowpopulation densities, and long traveldistances for rural persons to obtain care.

Given the apparent disparity betweenneed and the availability of services inrural areas, this project will explore theseissues through the development of a ruralsubstance abuse chartbook. Two nationalsurveys sponsored by the SubstanceAbuse and Mental Health Services


Administration will be used to examinethe prevalence of the use of differentsubstances relative to the availability anduse of treatment services, as well as howthis relationship may vary in ruralcommunities of different sizes, regions ofthe country, and among differentdemographic groups.

This project will produce acomprehensive national chartbook on theprevalence of the abuse of legal and

Research in the early 1990s indicated thatdepressed rural residents in a single statewere more likely than their urbancounterparts to be hospitalized fordepression and other health reasons overthe course of a year. This project willexplore whether depressed rural patientsresiding in multiple states are more likelythan their urban counterparts to behospitalized for depression and otherhealth reasons over the course of twoyears; explore whether any current rural-urban hospitalization differences arereduced in models which control forprevious intensive outpatient specialtycare utilization, suggesting that ruralproviders may still be substituting morerestrictive/expensive forms of depressiontreatment when intensive outpatientspecialty care is less available; andexplore rural-urban differences in theprevalence and consequences ofadministrative constraints on intensiveoutpatient specialty care use. Project staffwill address this question by conducting asecondary database analysis of the

Quality Improvement for Depression(QID) database. The QID databaseconsists of a consecutively sampledcohort of 1,498 depressed primary carepatients recruited from 108 practices in 14states (California, Colorado, Maryland,Michigan, Minnesota, New Jersey, NorthCarolina, North Dakota, Oklahoma,Oregon, Texas, Virginia, and Wisconsin);198 of these depressed primary carepatients are recruited from practices innon-MSA counties in 5 states (Colorado,Minnesota, North Dakota, Oregon, andWisconsin).

The major strength of this study isits ability to extend intriguing statewidefindings about rural service substitutionpatterns to a broader geographic areausing a more current longitudinaldatabase to examine how intensivespecialty care utilization impactssubsequent hospitalization, and howadministrative barriers impactsubsequent intensive specialty careutilization. This line of research willcontribute to the discussion of whether/

illegal substances across ruralpopulations, the extent to which ruralindividuals are receiving treatment fortheir substance abuse, barriers to thereceipt of treatment, and the distributionof substance abuse services across ruralareas. A rural substance abuse briefingpaper will also be prepared identifyingnational and regional issues for futurerural substance abuse research and policy.

Preventing Hospitalization in Depressed Rural PatientsWICHE Rural Mental Health Research Center

Expected completion date: September 2005Principal Investigator: Kathryn Rost, Ph.D., 303-221-3904 or

[email protected]: Federal Office of Rural Health Policy, HRSA


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how reduction of “excess”hospitalizations in depressed ruralpopulations could provide additionalmonies to expand outpatient specialtycare programs. This project can inform asystematic outreach intervention to ruralpurchasers to encourage health plans toprovide evidence-based outpatienttreatment rather than substituteexpensive hospitalization. This projectwill produce a manuscript for peer-reviewed publication, a working paper, aresearch summary, a brochure, and aconference/grand rounds presentation.

Bioterrorism Preparedness ■ �

Attention from the Top?Roles of State Offices of Rural Health Policy in

Preparing for Bioterrorism and Other Health System EmergenciesNORC Walsh Center for Rural Health Analysis

Expected completion date: December 2004Principal Investigator: Curt Mueller, Ph.D., 301-951-5070 or [email protected]


This project followed up with the stateoffices of rural health (SORH) to identifytheir current involvement withemergency preparedness in rural areas,particularly in the use of funds earmarkedfor bioterrorism preparedness. In 2002,the federal Office of Rural Health Policy(ORHP) released its report on emergencypreparedness in rural communities asperceived by directors of state offices ofrural health. Results of this studyindicated that although many of the stateoffices of rural health were participatingin planning, office respondents in anumber of states were concerned abouttheir state’s lack of resources forpreparedness in rural areas. Statedirectors expressed concerns over ruralhospital workforce shortages and whetherhospital and public health infrastructurecapacity was adequate for meetingpreparedness needs. Since release of thisreport, billions of dollars have been used

by the states to strengthen their capacityto respond to bioterrorist threats andother emergencies resulting fromterrorism. While general guidelines havebeen issued to assist state personnel withpreparation of plans for use of thesefunds, whether funds are to be explicitlytargeted to meet rural needs depends ondecisions by personnel in the states.

Walsh Center staff re-surveyed ruraloffices of the states and re-visited issuesthat were raised in the earlier ORHPsurvey. Roles of the offices wereidentified and information on the extentof office resources devoted to bioterrorismpreparedness were collected. Activitiesand roles of the most- and least-involvedstate offices were compared. A report andPolicy Brief will be prepared fordistribution to policymakers and personson the Center mailing list.

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Impact of Bioterrorism on RuralMental Health Needs

University of California, Los AngelesExpected Completion Date: August 2005

Principal Investigator: Jennie C. I. Tsao, Ph.D., 310-824-7667 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project aims to assess and im-prove the preparedness of rural primarycare professionals to care for mentalhealth conditions in the wake ofbioterrorism and other public healthemergencies. Relatively little attention has

been paid to the mental health needs of ruralcommunities in the wake of such majorcatastrophic events. Prior experience withnatural disasters suggests that firstresponders typically focus on immediatemedical trauma or injury, leaving rural

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communities to struggle with the burdenof unmet mental health needs both in theimmediate aftermath and over the longerterm.

This project will integrate qualitative(provider and administrator interviews)and quantitative (knowledge-basedtesting) methodologies to assess existingresources for mental health needs andanticipated resources that would benecessary following bioterrorism andsimilar mass casualty events. Based onthese findings, an intervention will bedeveloped to educate rural primary careproviders concerning important aspectsof mental health care. The educationalintervention will focus on post-traumaticstress disorder (PTSD), since PTSD hashigh post-event prevalence rates and yethas been neglected in primary caresettings relative to other mental disorderssuch as depression. Education focused onthe unique mental health concerns ofrural communities will increase thepreparedness of rural providers andthereby improve unmet local and

neighboring community health needsfollowing bioterrorism.Recommendations will be developed forpolicymakers to improve preparedness tomeet mental health needs in ruralcommunities following bioterrorist eventsand other public health emergencies.

Anticipated products from this projectinclude written educational materialsabout PTSD and related mental disordersfor rural primary care providers and aneducational in-service about thesepsychological disorders to be delivered atrural primary care practices. Anticipatedpublications from this project includepeer-reviewed and white papersdescribing the existing network of care formental health needs and how existingcare may be improved in anticipation ofbioterrorist events, and analysis of theimpact of the educational intervention onrural primary care providers’ knowledgeof likely post-event psychologicaldisorders.

Defining Rural ■ ��

Rural-Urban Commuting Area (RUCA)Development Project: Demographic Description and Frontier

EnhancementWWAMI Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: L. Gary Hart, Ph.D., 206-685-0401 or [email protected]: Federal Office of Rural Health Policy, HRSA

There is considerable current debate andpolitical lobbying about how to definefrontier areas. Rural-Urban CommutingAreas (RUCAs) are a new census tract-based classification scheme that utilizesthe standard Bureau of Census UrbanizedArea (UA) and Urban Place (UP) defini-tions in combination with commutinginformation to characterize all thenation’s census tracts regarding theirrural and urban status and relationships.The codes are based on whether a Censustract is located in a UA or UP and on thedestination of its largest and secondlargest commuting flows. The methodsused to accomplish the demographicdescription of the RUCA codes involved

standard cross-tabulation analysis of thecode areas nationally, regionally, and bystate.

This project augments the initialRUCA work by:■ Producing and describing the base

1998 demography of the RUCA codeareas

■ Creating quality state maps of theRUCA codes

■ Making this information and thecodes easily available on the Web athttp:/www.fammed.washington.edu/wwamirhrc/rucas/rucas.html.

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Emergency Medical Services ■ ��

Many rural areas are served by low-volume EMS providers. By definition,these providers are high cost providersbecause the costs of capacity cannot bespread over a larger number of EMStransports. Revenue sources of low-volume providers are varied, and the newMedicare Ambulance Fee Schedule maybe changing revenue for many providers.Under this environment, there may bestrong incentives for the rural hospital toacquire the local EMS provider. Thepurpose of this project was to clarifyissues surrounding the hospital’s decisionto acquire and maintain ownership ofcommunity ambulance services.Advantages and disadvantages ofownership are identified and analyzed,both conceptually, and informed by datafrom a national survey of ambulanceservice providers and informationobtained from hospital administrators,ambulance directors, and localgovernment officials who are familiarwith overseeing the provision ofemergency medical services.

Research questions under studyincluded the following:

■ What are the advantages anddisadvantages of hospital ownershipof an ambulance from the ruralhospital’s perspective?

■ What are the major economic andnon-economic challenges confrontingrural hospital-based ambulanceservice providers?

■ What are the advantages anddisadvantages of hospital ownershipof an ambulance from the ruralcommunity’s perspective?

■ Why is EMS hospital-based in somecommunities and not in others?

■ Are hospital-based ambulanceservices able to utilize more paid staff,thereby avoiding the extent of relianceon volunteer staff that oftencharacterizes government-operated,rural ambulance service providers?

■ Are hospital-based ambulanceservices better able to meet equipmentand supply costs than government-operated, rural ambulance serviceproviders?

■ What is the future of ambulanceownership by the hospital?

VEMERGENCY MEDICAL SERVICES (EMS)

Advantages and Disadvantages of Hospital-BasedEmergency Medical Services in Rural Areas

NORC Walsh Center for Rural Health AnalysisExpected completion date: December 2004

Principal Investigator: Curt D. Mueller, Ph.D., 301-951-5070 or [email protected]: Federal Office of Rural Health Policy, HRSA


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Health Insurance and the Uninsured ■ ��

VHEALTH INSURANCE AND THE UNINSURED

Effects of Uninsurance During the Preceding 10 Years on HealthStatus of Rural Working Age Adults

South Carolina Rural Health Research CenterExpected completion date: August 2005

Principal Investigator: Janice C. Probst, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project utilizes data from the 1979National Longitudinal Survey of Youth,which has over twenty years worth ofdata on individuals who were betweenthe ages of 14-22 in 1979, in order todetermine the effects of long-term,continuous uninsurance on health status.This study will compare people in ruraland urban areas to determine ifdifferences in health insurance and itseffect on health status occur betweenthese two populations.

The following hypotheses will betested:

■ Workers with longer periods ofuninsurance, in multivariate analysescontrolling for income, poverty andstatus/behavior at the beginning ofthe time period, will be more likely tobe overweight, to smoke, to reportexperiencing hypertension ordiabetes, or to describe their health as“fair” to “poor.”

■ Effects of uninsurance will be greaterin rural than in urban respondents,and greater for minority ruralpopulations than for white ruralpopulations.

Health Insurance Dynamics of Uninsured Rural FamiliesMaine Rural Health Research Center

Expected completion date: August 2005Principal Investigator: Andrew F. Coburn, Ph.D., 207-780-4435 or [email protected]

Contact Person: Erika Ziller, MS, 207-780-4615 or [email protected]: Federal Office of Rural Health Policy, HRSA

Numerous studies have found higheruninsured rates among rural versus urbanresidents, yet our understanding of thehealth insurance coverage of ruralfamilies remains limited. This is becausethe previous studies have focused on theinsurance status of rural individualsdespite growing recognition amongresearchers and policymakers that healthinsurance is what the Institute ofMedicine (IOM) calls “A Family Matter”(IOM 2002). To better understand thedynamics of insurance coverage amongrural and urban families, this study willuse the Medical Expenditure PanelSurvey (MEPS) to compare family healthinsurance coverage among non-elderlyrural and urban families.

This study has three objectives:■ In households with at least one

uninsured member, to determine ifthere are rural-urban differences infamily-level insurance status (fullyinsured, partially insured, orcompletely uninsured

■ Among families with mixed coverage,to identify the insurance status ofother family members (Medicare,Medicaid, employer-sponsored, andnon-group private)

■ To determine what employment andsocioeconomic characteristics areassociated with rural families’ healthinsurance mix and whether these


characteristics are the same ordifferent than for urban families.

Given that current strategies toaddress the uninsured appear to befocused almost exclusively onincremental health insurance reform, thefindings from this study will assist policy-makers in determining how to build on

existing insurance systems in ways thatwill be most effective for rural families.

Findings from this study will includea working paper, a research and policybrief, presentations at nationalconferences, and submission to a peer-reviewed journal.

Premium Assistance Programs: Exploring Public-PrivatePartnerships as a Vehicle for Expanding Health Insuranceto Rural UninsuredNorth Carolina Rural Health Research and Policy Analysis CenterExpected completion date: August 2005Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected] Person: Pam Silberman, JD, Dr.PH., 919-966-2670 or [email protected]: Federal Office of Rural Health Policy, HRSA

Many states have created public-private partnerships to expand healthinsurance coverage to the uninsured.Among these, one group of programs,“premium assistance programs,” aredesigned to help lower-wage workers paythe premium costs of their employer-sponsored health insurance. States canfinance premium assistance programsthrough state-only funds, or can seek toshare the costs with the federalgovernment through Medicaid and/orState Children’s Health InsuranceProgram (SCHIP) premium assistanceprograms. Recently, the Centers forMedicare and Medicaid Services (CMS)has given states more flexibility indesigning premium assistance programsthrough Health Insurance Flexibility andAccountability (HIFA) 1115 waivers.

Currently, there are 16 states that haveoperational premium assistanceprograms. This project will examine theexperience of those states inimplementing premium assistance

programs in rural areas. The project willassess whether there are certain designfeatures or certain types of ruralcommunities where these programs maybe more feasible. The study will includethree components:■ A survey of state Medicaid and/or

SCHIP agencies that haveimplemented or are consideringimplementing a premium assistanceprogram

■ A secondary data analysis of thecommunities in which premiumassistance programs have been mostsuccessful to determine characteristicsthat could explain the success orfailure of this program in differentgeographic locations

■ In-depth case studies of premiumassistance programs in four states.

Study results will be presented in aworking paper and findings brief.

Health Insurance and the Uninsured ■ ��

Trends in Uninsurance Among Rural Minority ChildrenSouth Carolina Rural Health Research Center

Expected completion date: December 2004Principal Investigator: Janice C. Probst, Ph.D., 803-251-6317 or [email protected]


Over the past decade, there have beenmultiple expansions of Medicaid accessfor children. Assessments of the effects ofthese expansions have yielded conflictingresults. The S-CHIP program reaches theend of its initially legislated funding in2006; OMB estimates that enrollment willbegin to decline in 2005. In order tocontribute to probable debate regardingcontinuation or evolution of S-CHIP, it isnecessary to ascertain whether theprogram has positively affected rural

children, and whether all rural children,including minority children, havebenefited equally. To provide perspective,and to distinguish, to the extent possible,between year-to-year fluctuations andlong term trends, trends in healthinsurance coverage and health servicesutilization among rural children wereanalyzed. Data was drawn from theNational Health Interview Survey, 1980through 2001.

Uninsurance and Welfare Reform in Rural AmericaRUPRI Center for Rural Health Policy Analysis

Expected completion date: April 2005Principal Investigator: Timothy D. McBride, Ph.D., 314-977-4094 or [email protected]


Former recipients of welfare are likely toface significant difficulties obtaininghealth insurance in rural areas, perhapseven greater than in urban areas,primarily because jobs in rural areas areless likely to offer health insurance butalso because difficulties with theMedicaid program might be exacerbatedin rural areas. The loss of health insurancecoverage for mothers who leave welfarecould impose a significant risk factor ontheir families, especially if the mother orchildren have health conditions ordisabilities. Women who have made thetransition to work but have lost theirhealth insurance coverage because the jobdoes not offer insurance coverage mayreturn to Temporary Assistance for NeedyFamilies (TANF) coverage, knowing thatTANF will provide Medicaid coverage.

This project will research thefollowing hypotheses:

■ Transitions off of welfare are often notaccompanied by the acquisition ofprivate health insurance or thecontinuation of Medicaid coverage

■ Transitions off of welfare,accompanied by health insurancecoverage, will lead to improved healthstatus, and improved access to healthcare, for former welfare recipients

■ Transitions off of welfare, notaccompanied by health insurancecoverage, will lead to declines inhealth status, and declines in access tohealth care, for former welfarerecipients.

This project will proceed in twophases. In the first phase, project staffwill use widely-accepted databases toexamine the recent history of uninsurancerates in the U.S., focusing on the low-income population that could be eligible


V

VV

for welfare. In the second phase, the focuswill be on how welfare reform hasimpacted the health insurance coverage ofwelfare recipients and other low-incomepersons over the period of time whenwelfare reform was phased in.

Why Are Health Care Costs Increasing andIs There a Rural Differential in National Data?RUPRI Center for Rural Health Policy AnalysisExpected completion date: April 2005Principal Investigator: Timothy D. McBride, Ph.D., 314-977-4094 or [email protected]: Federal Office of Rural Health Policy, HRSA

The project will be conducted in twophases. First, a concept document will beproduced discussing the reasons for therise in health care costs, and whether ornot we would expect to find a ruraldifferential. Second, MEPS data over timewill be used to analyze medical care costsin urban and rural areas. Two policypapers and two policy briefs will beproduced.

This project will determine whethergrowth in health insurance premiums andout-of-pocket spending differs in ruralareas as compared to urban areas. Risinghealth care spending is an increasingconcern to rural residents, employers,taxpayers, and legislators. Following asix-year period in which health carespending experienced an unprecedentedlull in growth, total health care spendingin the U.S. grew in 2000 and 2001.

Health Promotion ■ ��

Breast, Cervical, Colorectal, and ProstateCancer Screening in Rural America:

Does Proximity to a Metropolitan Area Matter?WWAMI Rural Health Research Center

Expected completion date: December 2004Principal Investigator: Mark Doescher, M.D., 206-616-9207 or [email protected]


VHEALTH PROMOTION

Because local cancer screening servicesfrequently are not available in rurallocations, many persons need to travelgreat distances to medical facilities forscreening. Lower levels of education,income and health insurance coverageamong rural residents and minoritygroup members serve as additionalbarriers to cancer screening. However,no studies using nationally representativedata have explored whether personsresiding in remote rural locations fareworse on cancer screening, and fewstudies have examined the issue of cancerscreening among rural minority groupmembers. For this study, non-public use

data from the Behavioral Risk FactorSurveillance System (BRFSS) was used toexplore the prevalence and trends ofscreening for four types of cancer(colorectal, breast, cervical, and prostate).The study compared screening ratesamong various levels of rural versusurban BRFSS respondents and amongwhite respondents versus those fromracial/ethnic minority groups. Thisproject will result in a policy brief and aworking paper. A manuscript will besubmitted for publication to a peer-reviewed journal, and findings will bepresented at appropriate regional andnational conferences.

Evaluation of the RWJ/HRSA Demonstration Project“Creating an Integrated Outreach System to Isolated Colonia

Residents in Hidalgo County, Texas”Southwest Rural Health Research Center

Expected completion date: August 2005Principal Investigator: Craig Blakely, Ph.D., 979-862-2419 or [email protected]

Funder: The Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation(RWJ), in a joint effort with the HealthResources Services Administration(HRSA), previously funded a majordemonstration project in the Rio GrandeValley targeting promotoras lay healthworkers in Colonias in Hidalgo County,Texas. The major goals of the demon-stration project included improving thecapacity of the lay health workers toimpact the health behaviors of the

residents, and integrating their activitieswith the actions of the health providers inthe area to change access and utilizationrates.

This project will provide a rigorousevaluation of the intervention activities inorder to determine the impact of theRWJ/HRSA demonstration project. Aseries of pre- and post-demonstrationhousehold surveys and analysis ofadministrative data from health services


facilities in the Colonias areas will beused to assess project impact. Inparticular, the evaluation will monitorcommunication patterns betweenpromotoras and residents as well aspromotoras and providers at variouslevels in the health delivery systems usedby residents. Attention will also be

directed to the impact of this interventionon the political and functionalinteractions of the relevant healthproviders. Finally, the project team willlook toward the potential of this model toimpact disaffected populations across theU.S./Mexico border region.

Rural Healthy People 2010 Expansion:Access to Long-Term Care and Rehabilitation Services,Educational and Community-Based Programs,and Public Health InfrastructureSouthwest Rural Health Research CenterExpected completion date: December 2004Principal Investigator: Larry Gamm, Ph.D., 979-458-2244 or [email protected]: Federal Office of Rural Health Policy, HRSA

The Rural Healthy People 2010 projectreviews research literature and models forpractice on rural health priority areasamong the Healthy People 2010 focusareas and objectives with a focus on ruralurban disparities in prevalence,morbidity/mortality, barriers, andproposed solutions. This project willexpand the work of Healthy People 2010by focusing on the rural constituency, anddocument any associated disparities,barriers, and solutions unique to ruralAmerica.

The companion document to dateaddresses the following focus areas:access to quality health services, cancer,diabetes, heart disease and stroke,immunization and infectious diseases,injury and violence prevention, maternal,infant, and child health, mental health

and mental disorders, nutrition, oralhealth, substance abuse, and tobacco use.

During the 2003-2004 project year, theproject researchers expanded thedocument by adding additional chaptersand associated models for practice in thefollowing topic areas: Education andCommunity-Based Programs, and PublicHealth Infrastructure. Three additionalchapters will be added in 2005: Access toLong Term Care and RehabilitationServices; Immunizations and InfectiousDiseases in Rural Areas; and Injury andViolence Prevention in Rural America.These five new focus areas and associatedmodels can be viewed at the RuralHealthy People 2010 website: http://www.srph.tamhsc.edu/centers/rhp2010.

Hospitals ■ ��

VHOSPITALS

Evaluation of New Hampshire’sRural Hospital Flexibility Program

Maine Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: John Gale, M.S., 207-228-8246 or [email protected]: Bureau of Rural Health and Primary Care, Department of Health and Human Services

Evaluation of the New Hampshire RuralHospital Flexibility Program(NH Flex Program) focuses on theexperience of the hospitals that haveconverted to Critical Access Hospital(CAH) status, the assistance provided tothe remaining hospitals that are eligiblefor conversion, and the satisfaction of thestaff of the hospitals and relatedcommunity organizations with thesupport and assistance provided to them.

Also being evaluated is the role of theAccess Improvement Plans prepared bythe CAHs to increase local collaboration,enhance primary care, improve access toprimary care, and strengthen theemergency medical services systems intheir communities. Data collection effortsinclude the review of documents andmaterials related to the NH Flex Program;interviews and focus groups with NHFlex Program staff, key state officials inagencies that collaborate with the NH

Flex Program, key stakeholders andmembers of the Rural Health AdvisoryCommittee, hospital and communityagency staff, and community repre-sentatives; and site visits to two hospitalsthat have converted or are in the processof converting to CAH status.

The evaluation team will analyze thisdata and prepare recommendations andfindings for the future development of theNH Flex Program. The evaluation teamwill also assist the NH Flex Program staffidentify performance measures tomonitor program implementation, andhelp program staff develop andimplement a performance monitoringsystem to guide the program. Thisperformance monitoring system will helpNew Hampshire to prepare for thedevelopment of Program Logic Modelsthat will be implemented as part of theevaluation of the National Rural HospitalFlexibility Program.

The Impact of Declining Access to Obstetric ServicesNORC Walsh Center for Rural Health Analysis

Expected completion date: December 2004Principal Investigator: Lan Zhao, Ph.D., 301-951-5070 or [email protected]


The latest medical malpractice insurancecrisis is once again bringing the issue ofaccess to medical care to public attention.Among the specialties most affected bythe current liability insurance crisis isobstetrics. This project investigated thereasons for the decline in the number ofhospitals offering obstetric services and

evaluate how this decline has affectedrural patients’ access to obstetric care andthe quality of health outcomes.

This project addressed the followingresearch questions:■ Is the number of rural counties where

hospital-based obstetric services areavailable continuing to decline?


Investments in Health Information Technology by Rural HospitalsNORC Walsh Center for Rural Health AnalysisExpected completion date: September 2005Principal Investigator: Julie A. Schoenman, Ph.D., 301-951-5074 [email protected]: Federal Office of Rural Health Policy, HRSA

Recent years have witnessed a rapidgrowth in interest in the application ofinformation technology (IT) to the healthcare industry for the purpose of improvingquality of care. Despite this burgeoninginterest, however, little is currently knownabout the scope of IT investments by ruralproviders or the factors affecting theiradoption of new information technologies.On the one hand, financially-strappedrural providers may decide that theycannot justify sizeable investments inhealth IT, particularly when many of thebenefits accrue directly to patients orinsurers rather than to the provider. Theseproviders may also lack the staff and otherinfrastructure required to select,implement, and maintain IT applications.On the other hand, the smaller scale ofrural health care systems may facilitate theimplementation of system-widetechnological advances, and the increasedfinancial stability experienced by most

critical access hospitals should improve theability of these rural facilities to invest inhealth IT.

This study will survey a large sampleof rural hospitals to gather data about theirIT investments. The sample will bestratified by the rurality of the hospital’slocation and by CAH status. Surveyquestions will ask about the hospital’s ITstructure and readiness for implementingIT systems; current applications used bythe hospital; integration of othercommunity-based providers (e.g., localphysicians, clinics) into the hospital’ssystem; barriers to adoption of health IT;benefits realized from health ITinvestments; and future plans for ITinvestments. Survey responses will becompared for different types of ruralhospitals, using a variety of bivariatemethods. The project will culminate in afinal report and a policy brief that will bewidely distributed.

■ What are the causes of the loss of localaccess to obstetric services inhospitals?

■ What is the impact of reduced accessto obstetric services provided in localhospitals?

■ What can be done to reverse the trendof declining access to obstetric care inrural areas, and what can be done toensure the quality of obstetric carewhere it is available?

Data from the American HospitalAssociation for the years 1989-1995 and2000 and from the Census Bureau, plusdata on the states’ scope of practice lawsand medical malpractice liability reformswere used to estimate the number ofhospitals no longer providing obstetric

care and to examine the factors underlyingthese changes. Natality data from theNational Center for Health Statistics(NCHS), including data on demographics,geographic area, and variables includingbirth weight, gestation, prenatal care,attendant at birth, and Apgar score wasused to estimate changes in sites ofdelivery and relationships with birthoutcomes. Experiences in countiesexperiencing a loss in obstetric resourceswas compared with experiences elsewhere.Interviews with members of communitiesexperiencing a loss of resourcessupplement empirical findings. A reportand policy brief along with policyrecommendations will be prepared fordistribution to policymakers and personson the Center mailing list.

Hospitals ■ ��

This study identified options fordevelopment of an equitableDisproportionate Share (DSH) paymentadjustment that accounts for hospitaluncompensated care costs, and deter-mined the financial impact of each ofthese proposals on rural hospitals. Ahospital’s eligibility to receive DSHpayments is based on a set of complexformulas that historically have beenbiased against rural hospitals. Comparedto their urban counterparts, ruralhospitals had to achieve a higherthreshold of low-income patients toqualify for DSH payments, and those thatdid qualify for this adjustment received alower fixed percentage add-on to the baseDRG payment amount. The Medicare,Medicaid, and SCHIP BenefitImprovement and Protection Act of 2000(BIPA) and the Medicare PrescriptionDrug, Improvement, and Modernization

Act made substantial advances towardachieving equity in the DSH formula.However, research suggests that morefundamental changes in the DSH formulaare necessary to ensure that the originalpurpose of the adjustment - preservingaccess to care for the poor – is achieved.

Walsh Center staff reviewed thehealth services literature to identifyalternative models or recommendationsfor revising the DSH payment toincorporate measures of uncompensatedcare, and used hospital financialstatement data from nine states tosimulate the impact of these changes.Results will be presented in the aggregateas well as by selected hospitalcharacteristics that include size, state,teaching status, and ownership. A reportand policy brief will be prepared fordistribution to policymakers and personson the Center mailing list.

Options for Structuring Disproportionate Share (DSH)Payments to Account for Uncompensated Care:

Impact on Rural HospitalsNORC Walsh Center for Rural Health Analysis

Expected completion date: December 2004Principal Investigator: Janet P. Sutton, Ph.D., 301-951-5070 or [email protected]


Patient Bypass Behavior and Critical Access Hospitals:Implications for Patient Retention

West Virginia University Institute for Health PolicyPrincipal Investigator: Jiexin (Jason) Liu, M.S., M.B.A., Ph.D., 304-347-1241 or [email protected]

Expected completion date: September 2005Funder: Federal Office of Rural Health Policy, HRSA

A number of patients “bypass” their localhealthcare providers and seek treatmentoutside their communities, often travelinglonger distances. This pattern is referredto as “bypass” hereafter. The purpose ofthis study is to identify policy issuesrelated to bypass in order to offerevidence and guidance to policymakers,hospital administrators, and

planners on the location of healthcareresources, the alteration of planningprograms, and the adjustment of policies inorder to retain patients locally. This study willidentify factors associated with bypass,reasons that some patients favor external(outside their immediate community)healthcare providers and bypass their localcommunity hospitals, and ways to retain


The number of small rural hospitalsthat have chosen to convert to CAHstatus has been greater than manypeople had anticipated, and concernhas been voiced by some individualsabout whether the provision ofservices in an intensive care unit (ICU)is appropriate in these institutions. Asinformation regarding ICUs in CAHsis currently extremely limited, thepurpose of this study is to inform any

policy process that aims to affect theprovision of ICU services in CAHs.

The study will describe the types ofcases treated and services provided, thenursing intensity of the care, and thealternatives (of lack thereof) available topatients. Information will be gatheredthrough telephone interviews withnursing directors at CAHs with ICUs. Thestudy findings will be presented in aworking paper and findings brief.

The Role of Intensive Care Units in Critical Access HospitalsNorth Carolina Rural Health Research and Policy Analysis CenterExpected completion date: February 2005Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected]: Federal Office of Rural Health Policy, HRSA

patients locally. This study will addressthese issues from the perspective of ruralresidents who have been hospitalized inthe last 12 months or received outpatientcare in the last six months. In addition,this study will assess how bypass patternsand travel distances/times impact ruralresidents’ health and their healthcareutilization.

Data will be collected through arandom telephone-based survey of thegeneral population within a 15-20 mile

radius of each of 25 randomly selectedIHPR designated rurally-defined, criticalaccess hospitals. A sample size of 1,000valid surveys will be collected with 40responses from each of the twenty five(25) designated hospitals. Each group of40 completed surveys will include 25subjects above the age of 18 who hadinpatient care in last 12 months and theremaining 15 who will have hadoutpatient care in last 6 months.

Hospitals: Rural Hospital Flexibility Program ■ ��

VHOSPITALS: Rural Hospital Flexibility Program

Rural Hospital Flexibility Performance Monitoring ProjectUniversity of Minnesota Rural Health Research Center,

Ira Mocovice, Ph.D.University of North Carolina Rural Health Research & Policy Analysis Center,

Rebecca Slifkin, Ph.D.University of Southern Maine Rural Health Research Center

Andrew F. Coburn, Ph.D.

Under contract with the federal Office ofRural Health Policy, the Rural HealthResearch Centers at the Universities ofMinnesota, North Carolina, and SouthernMaine (the Flex Monitoring Team) arecooperatively conducting a performancemonitoring project for the Medicare RuralHospital Flexibility Program (FlexProgram). The monitoring project willassess the impact of the Flex Program onrural hospitals and communities and therole of states in achieving overall programobjectives, including improving access toand the quality of health care services;improving the financial performance ofCritical Access Hospitals; and engagingrural communities in health care systemdevelopment.

The monitoring project has three maincomponents. The first component, “StatePerformance Management,” uses aProgram Logic Model approach to trackstate program activities and develop toolsthat allow states to systematically monitortheir accomplishments in the context ofFlex Program goals. The secondcomponent, “Institutional Performance,”uses secondary and primary data toassess the impact of the Flex Program onhospital financial status and quality ofcare, and to develop benchmarks for

financial performance and qualityimprovement for small rural hospitals.The third component, “CommunityImpact,” assesses the Flex Programimpact at the community level, includingthe local availability and accessibility ofhealth services, and the value ofcommunity partnerships developed withhealth care organizations.

The monitoring project has a strongdissemination component thatemphasizes rapid distribution ofinformation to key federal, state, hospital,and community stakeholders. The website for the Flex Monitoring team includesthe updated CAH list, the quarterly e-mail survey results, and an extensivepublications list. The web address ishttp://www.flexmonitoring.org.

In the coming year, the FlexMonitoring Team will continue the threecore components in its state-levelevaluation strategy: 1) the developmentand refinement of program logic modelsfor state performance management,monitoring, and evaluation; 2) theanalysis and synthesis of the 2004-2005state Flex grant plans; and 3) continuedtracking of CAH conversion and statelevel activities.


State Performance Management

Analysis of 2004-2005 State Flex Grant PlansMaine Rural Health Research CenterExpected completion date: March 2005Principal Investigator: Andrew F. Coburn, Ph.D., 207-780-4435 or [email protected] Person: John A. Gale, M.S., 207-228-8246 or [email protected]: Federal Office of Rural Health Policy, HRSA

As part of the Flex Monitoring Team’songoing work to monitor state level Flexprogram activities, the University ofSouthern Maine and the University ofMinnesota will collaborate to analyze andsynthesize the states’ annual state Flexprogram plans. The research team for thisproject will analyze state Flex grantapplications and related budget and workplan revisions using a data extractiontemplate. The analysis will focus on stateactivities in the core Flex program areas ofnetworks, quality improvement, andEMS. The data collected through thisprocess will be useful to individualmembers of the Flex Monitoring Team inconducting their research activities, such

as the EMS special study. A briefing paperwill be produced highlighting trends inthe development and implementation ofstate Flex programs. This paper willsummarize the range of activitiesundertaken by all participating statesacross the core Flex Program goals andhighlight interesting activities andinitiatives (e.g. EMS, QI, Networks) fromselect individual states. This paper will beuseful not only to state level Flexstakeholders who are interested in theactivities of other state Flex Programs butalso to national stakeholders who areinterested in an easily accessible summaryof the Flex Program.

Critical Access Hospital Conversion Tracking andQuarterly E-mail SurveysUniversity of North Carolina Rural Health Research & Policy Analysis CenterExpected completion date: August 2008Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected] Person: Indira Richardson, 919-966-5541 or [email protected]

This project will continue its worktracking Critical Access Hospital (CAH)conversions. A quarterly e-mail surveywill be sent to state Flex programcoordinators to monitor new CAHconversions and to identify emergingissues. Information gathered duringthese e-mail exchanges will be compiledand added to the CAH managementinformation dataset that is currentlyhoused at UNC. In addition, themanagement information dataset will be

updated with information on conversionssupplied by the Centers for Medicare andMedicaid Services. The products of thisactivity include a designated-CAHdataset; a spreadsheet, updated quarterly,that summarizes states’ CAHconversions; and a list of certified CAHs,which will be posted on the FlexMonitoring Team website (http://www.flexmonitoring.org/cahlist).


Using Program Logic Models to Monitor thePerformance of State Flex Programs

Maine Rural Health Research CenterExpected completion date: August 2008

Principal Investigator: Andrew F. Coburn, Ph.D., 207-780-4435 [email protected]

Contact Person: John A. Gale, M.S., 207-228-8246 or [email protected]

This project will use a program logicmodel approach to track state programactivities and develop tools that allowstates to systematically monitor andmanage their accomplishments in thecontext of Flex Program goals. As appliedto a state Flex Program, a program logicmodel provides a systematic way topresent the relationships among theresources available to operate a program,the activities planned under the program,and the results that are expected as aresult of undertaking those activities. Theprogram logic model links short and longterm outcomes with program activities/processes and resources of the stateprogram.

To insure the development of aprogram logic model that is useful to thestates, project staff will work with thefederal Office of Rural Health Policy(ORHP), TASC, the Flex Committee of theNational Organization of State Offices ofRural Health, and six state Flex Programsduring the second year of the project(2004-05) to refine the generic nationalFlex Program logic model and finalize the

toolkit that other states may use toimplement their own Flex Program logicmodels. The demonstration states willalso receive help from project staff tocustomize and implement the model fortheir programs and to use the model as astrategic planning tool to manage theirprograms. Refinements to the model willbe made based on feedback from the sixstates and the project partners.

To further insure the applicability ofthe Flex Program logic model to thestates, the Flex Monitoring ProjectAdvisory Committee will help guide theprocess, provide input into thedevelopment of the models, and offerfeedback on the materials and process.During the subsequent years of thisproject, the revised program logic modeland toolkit will be offered to all state FlexPrograms who choose to use it forpurposes of managing their programs andproviding data to the Flex MonitoringTeam.

Institutional Performance

Analyzing the Relationships among Critical Access HospitalFinancial Status, Organizational Linkages, and Scope of Services

University of Minnesota Rural Health Research CenterExpected completion date: August 2005

Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected] Person: Michelle Casey, M.S., 612-627-4251 or [email protected]

This project will systematically analyzethe relationships among pre- and post-conversion Critical Access Hospital(CAH) financial performance, the

organizational linkages in which thehospital participates (e.g., health caresystems and/or networks), and the scopeof services (i.e., the number and type of


services) provided. The project will usedata from four sources: Medicare costreports, three national surveys of CAHsconducted by the Tracking Project and theMonitoring Team in 2000, 2001, and 2004,the American Hospital Association annualsurvey of hospitals, and the AreaResource File.

Research questions to be addressed bythis project include the following:■ To what extent does improved

financial performance (as reflected inoperating margins) allow CAHs toadd and/or expand specific services?

■ Are expansions in these services mostlikely to occur within 2 years afterconversion, or more than 2 years afterconversion?

■ Does participation in a system and/ora network increase the likelihood that

a CAH will expand and/or addspecific services post-conversion?

■ Are CAHs that have strongerrelationships with their supporthospitals more likely to expand and/or add specific services?

■ What are the characteristics (e.g. scopeof services, organizational linkages) ofCAHs that exhibit improved financialperformance in the short term?

A final report describing the results ofthe analyses will be prepared anddisseminated at the end of 2005.

Developing a Quality Performance MeasurementSystem for Critical Access HospitalsUniversity of Minnesota Rural Health Research CenterExpected completion date: August 2006Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected]

This project will measure changes in thequality of care provided by CAHs bydeveloping and testing a prototypeperformance system that will provideinformation on a core set of CAH qualitymeasures on an ongoing basis. In Year 1of the project (2003-04), we identified aninitial core set of 20 quality measuresrelevant for rural hospitals with less than50 beds. In conjunction with anotherproject supported by CMS, we currentlyare field testing the feasibility ofcollecting and using these qualitymeasures in 20 rural hospitals inMinnesota, Utah and Nevada incollaboration with the two QualityImprovement Organizations (QIOs)responsible for those three states. DuringYear 2 of the project (2004-05), we willfurther refine and field test the ruralhospital quality performancemeasurement system and assess its

relevance for CAHs. The field test of therevised set of CAH quality performancemeasures will begin during the final twoquarters of Year 2. The field test willrequire approximately 15 months tocomplete with the first six monthsdedicated to state selection, QIO/Flex andhospital association staff training, hospitalrecruitment, development of datacollection tools and hospital staff training;the next six months dedicated to hospitaldata collection; and the last three monthsdedicated to analysis and final reportwriting.

The final report will be available bythe end of Year 3 (2006) of the project andwill document the complete set ofactivities involved with the development,testing and implementation of a CAHquality performance measurementsystem.


Financial Performance Measures of Critical Access HospitalsUniversity of North Carolina Rural Health Research & Policy Analysis Center

Expected completion date: August 2008Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected]

Contact Person: George Pink, Ph.D. 919-966-5541 or [email protected]

This project will use research and expertopinion to select dimensions andindicators of financial performance,develop appropriate bases or methods ofpeer comparison, investigate therelationship between quality of care andfinancial performance, and identifycharacteristics of high performing CAHs.Investigation will start with a review ofacademic and practitioner journals,reports, websites, and the data andmethods used by existing performanceinitiatives.

An expert advisory committee ofCAH managers, health practitioners and

policy analysts will be assembled toevaluate the validity and usefulness ofperformance dimensions and indicators.Multiple passes of indicators for allCAHs, including descriptive statistics andscatter plots will be generated. Outlierswill be investigated and an extensivesearch of data errors and problems will beundertaken. Findings will be presentedthat investigate the relationship betweenCAH financial performance and thequality of care provided.

This project will evaluate the impact ofthe Flex program on local communities.Activities will focus on identifying theways in which the program could have ameasurable effect, as well as the ways inwhich Flex program coordinatorsintended to affect community health. InYear 2 of this project (2004-05), we willproduce a briefing paper that integratesinformation on scope of services,networking, and quality. Thisinformation will be used to assess CAHs’efforts to add or revise services whichenhance the health of the communitiesthey serve, create new partnerships andnetworking relationships that willpresumably result in better and moreefficient care, make capital improvementsor improve available medical technology,and improve patient care processes. In

Community Impact

Community Impact AssessmentUniversity of North Carolina Rural Health Research & Policy Analysis Center

Expected completion date: August 2008Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected]

Year 2 we will also conduct case studies insix CAH communities. The purpose ofthese case studies is threefold:■ To serve as a mechanism for

validating our conceptual frameworkof community impact

■ To investigate and describe places thatare identified as good examples ofFlex program activities that havefocused on local communities,including details on the processes andoutcomes of these activities

■ To help us identify additionaldimensions of community impact thatshould be included in our Year 3telephone survey, and potential futurecommunity impact activities.


Special Study

Special Study of EMS IssuesMaine Rural Health Research CenterExpected completion date: January 2005Principal Investigator: Andrew F. Coburn, Ph.D., 207-780-4435 or [email protected] Person: John A. Gale, M.S., 207-228-8246 or [email protected]

The University of Southern Maine and theUniversity of North Carolina at ChapelHill will collaborate to conduct a specialstudy of EMS issues during Year 2 of theFlex Project (2004-05). The study willfocus on state, community, and hospitallevel initiatives designed to build theinfrastructure to support EMS servicecapacity and encourage the integration ofthese services into the rural healthcareinfrastructure in the areas of qualityimprovement, financing, staffing, medicalcontrol, and networking and integration.Using data from multiple sources, thestudy will identify six “promising EMSpractices” for further study and analysis.Telephone interviews will be conductedwith the broad range of key informants

involved with these programs tounderstand their goals and objectives, thedevelopment of these “promisingpractices,” the resources and partnershipsnecessary to undertake these initiatives,the role of the Flex Program in supportingthese initiatives, the barriers toimplementation, and the extent to whichthese initiatives can be replicated by otherstates and communities. The study willfocus on initiatives designed to build longterm capacity to support and enhanceEMS services at the hospital andcommunity level.

Long Term Care ■ ��

The Burden of Chronic Illness AmongRural Residents: A National Study

WWAMI Rural Health Research CenterExpected completion date: August 2005

Principal Investigator: Mark Doescher, M.D., MSPH, 206-616-9207 or [email protected]: Federal Office of Rural Health Policy, HRSA; RWJ Foundation/AHRQ

VLONG TERM CARE

Better information about the prevalenceof and trends in chronic illness is neededfor rural Americans. This study will usedata from the Behavioral Risk FactorSurveillance System (BRFSS) to examinethe prevalence of and trends in fourimportant conditions—hypertension,diabetes, hypercholesterolemia, andasthma—by type of geographic locationand by key risk factors. The study alsowill explore patterns of screening for twoof these conditions, hypertension andhypercholesterolemia. The aim is todetermine the prevalence of and trends ineach of these four conditions among allrural BRFSS respondents and also amongrural minority group members andresidents of remote rural counties.Similarly, the study will assess theprevalence of and trends in screening forhypertension and hypercholesterolemiaamong rural residents overall and amongrural minority group members andresidents of remote rural counties.

For this study, annual BRFSS datafrom 1994 to 2003 will be used. Chi-square testing will be used to compareunadjusted prevalence rates of eachcondition or screening by geographiccategory and race/ethnicity. Logisticregression analyses will be performed tocompare outcomes adjusted forsociodemographic, health and health caresystem factors. Trend assessment willinclude time (in years) as an additionalcovariate in models. This project willresult in at least two policy-briefs and aworking paper that will be distributedwidely to researchers and policymakersinterested in the health of ruralAmericans. Also, at least two manuscriptswill be submitted for publication to apeer-reviewed journal emphasizingprevention or rural health. Presentationsat appropriate regional and nationalconferences will also be given.

Disability Burdens Among Ruraland Urban Older Americans


Principal Investigator: James Laditka, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

The number of older Americans isprojected to grow dramatically over thenext several decades, and will includemore minorities. Costs of providingformal long-term health care are alsogrowing rapidly, exceeding $100 billion.There is evidence that disability trends

vary substantially among groups of olderAmericans. Compared with men, womenlive longer, and live a greater percentageof their lives with severe disability.Compared with whites, AfricanAmericans live shorter, more disabledlives. Less is known about disability


patterns over the later life course by areaof residence. Some research suggests thatpeople living in rural areas have lowerlevels of disability and mortality thanthose in urban areas. This is paradoxicalin that people living in rural areasgenerally are less likely to have healthinsurance, have lower incomes, have lessaccess to health services, and have greatertravel time to obtain health care.

This project will use the 1994-2000Second Longitudinal Study of Aging, anationally representative sample ofcommunity-dwelling adults age 70 andover, to develop detailed estimates ofhealthy, disabled, and total lifeexpectancy among rural and urban

Medicaid Budget Cuts:Effects on Rural Nursing Homes andRural Elderly and DisabledSouthwest Rural Health Research CenterExpected completion date: April 2005Contact Person: Charles D. Phillips, Ph.D., MPH, 979-458-0080 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will investigate whethernursing home quality and access tonursing home care have eroded in ruralareas as a result of changes in Medicarepayments or reductions in Medicaidnursing home payments over the periodfrom calendar year 2000 to calendar year2003. The basic, general hypothesis forthis study is that rural nursing homes andthose frail elderly in rural areas will bemore disadvantaged by these changesthan the facilities and elderly in othertypes of areas. To test this hypothesis,

researchers will analyze national facilityand resident level data combined withsurveys of Medicaid state agencies todetermine the impact of cuts to Medicareand Medicaid services on quality andavailability of long term care in ruralversus urban areas. In addition to a finalreport submitted to the federal Office ofRural Health Policy that will be madeavailable on-line at the Center’s website,the key findings will also be published inprofessional journals.

populations. To address anticipateddifferences among populations, we willdevelop and compare the estimatesbetween women and men, by race/ethnicity, and across differing levels ofeducation. A greater understanding ofdifferences in the burden of disabilityamong groups defined by thesecharacteristics would help national andlocal policymakers anticipate needs forservices of various types.

Findings from this study will bepresented at national meetings addressingrural health policy issues in addition topapers submitted to peer-reviewedjournals.

Long Term Care ■ ��

Medicaid Budget Cuts and Long-Term Care SupplementSouthwest Rural Health Research Center

Expected completion date: December 2004Contact Person: Catherine Hawes, Ph.D., 979-458-0081 or [email protected],


According to the National Governor’sAssociation and the National Conferenceof State Legislators, the majority of statesare facing serious budget crises. To meetthis challenge, states are turning to avariety of mechanisms to decreaseexpenditures including cuts to Medicaid,a significant source of state expenditures.While children and those who would beuninsured without current state programsare at significant risk, the elderly and

disabled also face significant reductionsin services. This project collected data oneach state, identifying all the changesmade to their Medicaid program in thearea of long-term care or related servicesto the frail elderly and disabled. A policypaper addressing the impact of Medicaidcuts on long term care services, particu-larly among the elderly in rural areas, willbe produced.

Rural and Urban Differences inUtilization of Formal Home Care

Agency for Healthcare Research and QualityExpected completion date: August 2005

Principal Investigator: William J. McAuley, Ph.D., 301-427-1412 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project is using the MedicalExpenditure Panel Survey HouseholdComponent (MEPS-HC), the AreaResource File, CMS Provider of Servicedata, and other data sources to examinerural and urban differences in theutilization and costs of formal home care,including changes in utilization patternsand costs across residence types overtime. The paper, based upon the 1998MEPS-HC data, examined the factors thatpredict use of formal home care,including rurality. A major finding is thatwithout adjustments older people in morerural counties (nonmetropolitan countieshaving no town of 10,000) aresignificantly more likely to use any formalhealth care, as well as Medicare homehealth care. Fully adjusted logisticanalysis results point to an interplaybetween residential status and Medicaidcoverage with regard to formal home careuse. In comparison with metropolitanresidents covered by Medicaid, theadjusted relative risk of formal home care

use from any source is significantlyhigher for Medicaid enrollees residing innonmetropolitan counties having nopeople of 10,000 or more. Use of Medicarehome health care is significantly greaterfor residents of the most rural counties,irrespective of their Medicaid coverage, aswell as Medicaid-covered residents ofnonmetropolitan counties having a townof at least 10,000 people. A second paper,examining rural and urban differences inthe cost of formal home care, is in process.Following these papers, more in-depthanalyses of rural and urban differences inutilization and cost trends will becompleted. The MEPS-HC is a very usefulresource for the examination of formalhome care utilization because its questionformat leads to the gathering ofinformation on reimbursed home care ofall types and from all sources.


Trends in Swing Bed and Skilled Nursing FacilityUse in Rural Hospitals, 1996-2003North Carolina Rural Health Research and Policy Analysis CenterExpected completion date: August 2005Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected] Person: Kathleen Dalton, Ph.D., 919-966-7957 [email protected]: Federal Office of Rural Health Policy, HRSA

This study will examine trends in thedistribution of skilled nursing facility(SNF) services in rural hospitals during aperiod of dramatic change in Medicarereimbursement, most notably thetransition from cost-based reimbursementto SNF prospective payment system(PPS). The supply and organization ofskilled nursing care have been shown tobe very sensitive to changes in Medicareregulations, as the majority of patientsreceiving SNF services following ahospitalization are elderly or disabled,and the majority of such services arecovered by Medicare. Using nationallicensure files for information on supply,and Medicare’s hospital and nursingfacility cost reports for information oncosts and utilization, we propose toanalyze changes in the role of ruralhospitals in providing SNF services asthey respond to the new reimbursementenvironment.

The primary study objectives are todocument changes in rural hospitals’skilled nursing care delivery, and toidentify rural hospitals’ responses tochanges in skilled nursing payments.While many of the measures describedabove are tracked by CMS and areavailable at the national level, they havenot been documented specifically forrural providers, or at the detailed level ofrural-urban continuum codes. Thesequestions, therefore, will be addressedwith extensive descriptive statistics.Multivariate models will be constructedto identify geographic and organizationalfactors associated with changes inhospital SNF participation over time, andto investigate differences between PPSand CAH providers. Findings will bepresented in a working paper describingall parts of the study, plus two to threemore narrowly focused findings briefs onspecific topics.

Medicaid and S�CHIP ■ ��

VMEDICAID and S�CHIP

Access to Health Care forYoung Rural Medicaid Beneficiaries

North Carolina Rural Health Research and Policy Analysis CenterExpected completion date: February 2005

Principal Investigator: Victoria Freeman, DrPH, RN, 919-966-6168 or [email protected]: Federal Office of Rural Health Policy, HRSA

This study examined access to health careamong rural children ages 0-17 who areenrolled in some type of Medicaidmanaged care program, and comparedthis access across types of programs and,within program type, to that of urbanbeneficiaries. Access to care was assessedby means of a mailed survey sent to theparents of Medicaid children in four

Impact of The Medicaid Budget Crisison Rural Communities: A 50-State Survey

North Carolina Rural Health Research and Policy Analysis CenterExpected completion date: February 2005

Principal Investigator: Rebecca Slifkin, Ph.D. 919-966-5541 or [email protected] Person: Pam Silberman, JD, DrPH., 919-966-2670 or [email protected]


associations. The organizations weresurveyed on topics such as specificoptions states have taken to reduceMedicaid expenditures, whether providerparticipation in Medicaid has changedover the last three years, changes ineligibles, and potential interest states havein recent proposals to block-grant theMedicaid program. The study findingswill be presented in a short policy briefand a paper submitted to a peer-reviewedjournal.

Most states are facing severe budgetcrises, forcing them to reduce Medicaidprogram costs. States have many differentoptions to reduce Medicaid expenditures,including cutting optional eligibles oroptional services, reducing providerpayments and increasing recipient costsharing. Many of the states’ actions toreduce Medicaid program costs may havea differential impact in rural areas.

In an attempt to ascertain the impactof Medicaid cuts on rural recipients andproviders, project staff conducted a 50-state survey of state Medicaid agencies,offices of rural health and rural health

states chosen for their geographic diversity.Questions focused on such issues as theability to find a participating health careprovider within a reasonable distance,coordination of care concerning services suchas specialty care that are more likely to belocated in urban areas, use of dental services,and transportation problems.


A National Study of Rural Medicaid Disease ManagementThe Council of State GovernmentsExpected completion date: August 2005Principal Investigator: Trudi L. Matthews, M.A., 859-244-8157 or [email protected]: Federal Office of Rural Health Policy, HRSA

Currently there are differing estimates ofthe number of states offering diseasemanagement (DM) services throughMedicaid. It is also not known how manyMedicaid disease management programsoffer services to rural clients. The Councilof State Governments (CSG) will conducta national study of Medicaid diseasemanagement programs to determine howmany states provide DM services in ruralareas and what the opportunities andchallenges are for states establishing DMprograms that serve rural areas. Theprimary research component will be anational survey of all state Medicaidprograms. This survey will identifywhich states offer disease management(DM) through Medicaid managed carecontracts or through stand alone diseasemanagement programs. The survey will

also identify where these programsoperate in rural areas and identify theunique challenges that state DMprograms in rural areas face. CSG’sresearch team will also produce ananalysis of state and federal legislationand regulation related to Medicaiddisease management in rural areas. Basedon the survey results and legal analysis,CSG will conduct thorough interviewswith four states that can serve as bestpractice case studies for operatingMedicaid DM in rural areas. CSG willprepare a policy brief and other resourcesbased on the study results that will bedisseminated to state legislative andexecutive branch policymakers.

The State Child Health Insurance Program (S-CHIP) and Access toMedical Transportation Program ServicesSouthwest Rural Health Research CenterExpected completion date: December 2004Contact Person: Craig Blakely, Ph.D., MPH, 979/862-2419 or [email protected]: Federal Office of Rural Health Policy, HRSA

In 1997, Congress created the StateChildren’s Health Insurance Program(S-CHIP) in response to concern over thegrowing number of children and familiesnationally without health insurance.Despite the growth and expansion of S-CHIP, there is practically no empiricalinformation available regarding either theuse of S-CHIP resources to assure accessto medical services or analysis of thebarriers to adequate transportation.Given this disparity, the purpose of thisresearch was to create a typology of S-CHIP models and the interface betweeneach and the existing Medical

Transportation Program (MTP) availableto Medicaid recipients in select states.

In addition, the project comparedrural and non-rural variances in patternsof utilization of MTP service in S-CHIPprograms, and identified the strengthsand weaknesses of the variousapproaches utilized by the different stateMTP models. Finally, the projectcompared the performance of the variousstate models in assuring access to coveredmedical services and identified barriers toS-CHIP services.

Medicare ■ ��

Access to State-of-the-Art Hospice Care forRural and Minority Hospice Users

University of Minnesota Rural Health Research CenterExpected completion date: December 2006

Principal Investigator: Beth Virnig, Ph.D., 612-624-4425 or [email protected]: American Cancer Society

This project will develop and maphospice care service areas that will allowfor the measurement of access to hospicecare for rural and minority Medicarebeneficiaries who die of cancer, andrecommend options for increasing accessto hospice care in underserved ruralareas. This project will incorporate theanalysis of home health service areasconducted by Dr. Virnig. This analysiswill use the Medicare 100% hospice and100% denominator files for 1999, 2000,and 2001. Using Medicare cost reportdata, the project will also evaluate theeffect of hospice size, ownership and

rural/urban location on amount ofMedicare payments allocated topharmacy costs, use of radiation orchemotherapy; estimate the proportion ofthe population served by freestandinghospices providing limited availability tosuch treatments; and recommend optionsfor improving access to these symptommanagement options for hospice patientswith cancer. Final products will include amap of hospice service areas along withan analysis of both home health andhospice service areas.

Access to Physician Care for the Rural Medicare ElderlyWWAMI Rural Health Research Center

Expected completion date: February 2005Contact: L. Gary Hart, Ph.D., 206-685-0402 or [email protected]


There is some concern that the careprovided to elderly Medicarebeneficiaries living in small and isolatedrural towns is less, more distant, andreflects a different mix of specialist carethan their urban and large rural citycounterparts. This study describes whereMedicare beneficiaries in five statesobtain their health care, how far theytravel for that care, and the mix ofphysician specialties from which theyobtain ambulatory care. Special attentionwas paid to beneficiaries who have dualMedicare-Medicaid status, who reside inpoorer income areas, and who live indesignated Health Professional ShortageAreas. Analyses examined the careobtained by beneficiaries with selected

chronic conditions. The data uponwhich the analyses were based consistedof the 1998 Medicare Part B data forSouth Carolina, North Carolina, Idaho,Alaska, and Washington. These datacontain information on physician visits,specialty type, patient home andencounter locations, diagnoses andprocedures, and patient demographics.Demographic and Rural-UrbanCommuting Area (RUCA) codes werelinked to the encounter data, and roadtravel distances and times involved inobtaining care are being determined.

VMEDICARE


Assessing the Community Impact of the MMARUPRI Center for Rural Health Policy AnalysisExpected completion date: August 2005Principal Investigator: Keith J. Mueller, Ph.D., 402- 559-4318, [email protected]: Federal Office of Rural Health Policy, HRSA

This project will measure the community-level impacts of the Medicare PrescriptionDrug, Improvement, and ModernizationAct of 2003 (MMA) and will provideimmediate feedback to policymakersregarding the impact of the MMA on itspolicy targets (providers andbeneficiaries), in the context of ruralplaces. This project will also establish amethodology for studying communityimpacts of health policies that will be thebasis of a broader effort within the RuralPolicy Research Institute to study theimpacts of national policies on ruralplaces.

There are two levels to thisanalytical plan: (1) the proximate effectsof policy change on the targeted personsand organizations and (2) the effects onthe broader community. Four ruralcommunities will be selected for detailedstudy, from four different regions of thecountry. The immediate impacts of theMMA will be assessed with quantitativeand qualitative data derived from

activities of local providers, includingpharmacies, hospitals, ambulanceproviders, home health agencies, skillednursing homes, federally qualified healthcenters, rural health clinics, and physicianclinics. A unique contribution of thisstudy will be measuring the aggregateeffect of the multiple changes to paymentand regulatory policy on the health sectorof rural communities. The immediateeffect of the prescription drug discountcard will be assessed by measuring itslocal use with qualitative assessmentssupplied by agencies serving the elderlyof the community. The broadercommunity impacts of the MMA will beassessed using a modification of theSocial Accounting Matrix approach.

Products of this research willinclude a study methodology suitable forreplication by others, a policy brief basedon the quantitative analysis, a policypaper based on the total analysis, andjournal submission based on the totalanalysis.

Chronic Disease Management in Rural Areas:Examination of Medicare and MedicaidManaged Care ProgramsSouthwest Rural Health Research CenterExpected completion date: December 2004Principal Investigator: Jane Bolin, Ph.D., JD, RN, 979-862-4238 or [email protected]: Federal Office of Rural Health Policy, HRSA

Rural populations show higher incidenceof disease in a number of areas includingheart disease, respiratory disease,disability associated with chronic healthconditions, and obesity. Disease manage-ment (DM) is an appropriate tool tocoordinate care and improve healthoutcomes for such populations and to

reduce needs for more costly care. DM,however, has been most widely utilizedin urban settings where it is promotedby large health plans interested inefficiently reaching large numbers ofenrollees to reduce costs of care whileimproving outcomes. The goal of thisproject is to advance knowledge of the

Medicare ■ ��

use of DM to address chronic conditionsamong rural populations. Of particularinterest is information from participatinghealth plans and providers about specialchallenges and effective strategies in DMinitiatives targeting rural populations.

Based on analysis of this information, theproject team identified issues of publicpolicy and service management that canadvance effective DM for ruralpopulations.

Colorectal Cancer Care Variation in Vulnerable ElderlyWWAMI Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: Laura-Mae Baldwin, M.D., M.P.H., 206-685-0401 [email protected]

Funder: The National Cancer Institute

This study, aimed at improving colorectalcancer care for the elderly, examineddifferences in receipt, diffusion, and costof recommended colorectal cancertreatments between more and lessvulnerable elderly populations, andevaluated different measures ofcomorbidity and costs.

The project was conducted by amultidisciplinary research team consistingof members of the Department of FamilyMedicine, Group Health, the Departmentof Gastroenterology, the Department ofSurgery, and the Department ofRadiology. A supplemental study, alsofunded by the National Cancer Institute,

compared quality of surgical care forcolorectal cancer and the extent ofsurgical complications across differentMedicare populations. A more recentNCI-funded study is comparing non-cancer care for Medicare beneficiarieswith and without colorectal cancer, and astudy has just been funded by the Centersfor Disease Control to examine healthsystems in which ovarian cancer patientsreceive care in eight states, to identifywhether vulnerable populations receivecare in systems associated with favorableoutcomes. Several papers are currently indraft form and will be submitted forpublication by the end of the year.

Impact of the Home Health PPS on Access in Rural AmericaNORC Walsh Center for Rural Health Analysis

Expected completion date: May 2005Principal Investigator: Janet P. Sutton, Ph.D., 301-951-5070 or [email protected]


This study is designed to provideinformation on how the shift toprospective payment has affected accessto home care in rural communities. Thehome health prospective payment system(PPS) was implemented in October 2000to reduce growth in Medicare homehealth expenditures. Under the PPS,home care agencies are reimbursed basedon a 60-day episode of care, withadjustments to the base payment thatreflect differences in resource needs. This

case-mix adjustment classifies homehealth patients into Home HealthResource Groups (HHRGs) based on theirclinical characteristics, functional status,and service utilization. This study isdesigned to provide information on howthe shift to prospective payment hasaffected access to home care in ruralcommunities. This study will explore theimpact of the PPS on patterns of homehealth utilization. The following researchquestions will be examined:


■ How do the demographic and clinicalcharacteristics of rural and urbanMedicare beneficiaries who receivedhome care prior to the PPS compare tothose who received home carefollowing the PPS?

■ Are there subgroups of rural andurban beneficiaries for whom accessto home care is more limitedfollowing implementation of the PPS?For whom home care is moreaccessible following implementationof the PPS?

■ To what extent has the PPS had aneffect on patterns of home careutilization?

■ Has the quality of care provided tohome care users been affected by thePPS?

Data to conduct this study will beobtained from the 5 percent MEDPAR fileand the Home Health 5-percent StandardAnalytical File.

Is Medicare Beneficiary Access to PrimaryCare Physicians at Risk?RUPRI Center for Rural Health Policy AnalysisExpected completion date: June 2005Principal Investigator: Keith J. Mueller, Ph.D., 402-559-4318 or [email protected]: Office of Rural Health Policy, HRSA

This project will examine the impact ofchanges in Medicare payment tophysicians on access to care for ruralbeneficiaries. If rural practices arethreatened by the cumulative effects ofreduced payment and increasedexpenditures, physicians may be forced toabandon the community to merge intolarger urban-based practices, perhaps inother states. Access to primary careservices would decline, and a vitalcontribution to the local social capital andeconomic development would be lost.

This project will research thefollowing hypotheses:■ Rural primary care physicians are

more likely to declare policies not tosee new Medicare patients than areurban primary care physicians orspecialists (urban or rural)

■ Rural primary care physicians are lesslikely to declare policies not to seenew Medicare patients than are urbanprimary care physicians, due to thefactor of “everybody knowseverybody”

■ Declines in seeing new Medicarepatients will vary by region of thecountry, related to the percent elderlyin the region, payment from othersources, and practice costs

■ The primary reason physicians ceaseto accept new Medicare patients is therate of payment; secondary reasonsinclude complexity of the Medicareprogram, intensity of treatmentneeded for elderly patients, andpersonal preference.

Three completed surveys will be usedto address these issues, with multipleregression analysis as the principalmethodology used to analyze those data.In addition, a telephone survey will beconducted with a sample of state medicalassociations and state chapters of theAmerican Academy of Family Medicine.Based on the telephone survey, three sitevisits will be made for the purpose ofgaining a more in-depth understanding ofthe economic and other effects of treatinga significant percentage of elderlypatients on rural primary care practices.

Medicare ■ �

Medicare Beneficiary Outcomes in Rural and UrbanHome Health Agencies

NORC Walsh Center for Rural Health AnalysisExpected completion date: August 2005

Principal Investigator: Janet P. Sutton, Ph.D., 301-951-5070 or [email protected]: Federal Office of Rural Health Policy, HRSA

The home health prospective paymentsystem (PPS) resulted in major changes inpatterns of utilization of home careservices. There is some evidence tosuggest that some of the post-PPSchanges in utilization could compromisequality of care. To date there is littleempirical information to assess thequality of home care services and how itvaries by rural and urban location. Thisstudy is designed to compare theperformance of rural and urban homecare agencies and to identify the agencycharacteristics that contribute to betterpatient care outcomes. Of particularinterest, this study will ascertain whetherthe availability of and pattern ofutilization of skilled and ancillary servicesfollowing implementation of the homehealth agency PPS is related toperformance.

This study will address the followingresearch questions:

■ Do rural and urban home healthagencies differ in the quality of homecare provided?

■ To what extent are the followingagency characteristics associated withbetter or worse outcomes?

■ To what extent do differences in staffcomposition, caseload and serviceintensity contribute to differences inpatient outcomes?

Data for this study will be obtainedfrom the Medicare Providers of Servicesfile and the Medicare Home HealthCompare (HHC) database. Results willprovide preliminary data that may beused in the on-going monitoring ofMedicare home care policies on ruralcommunities. Results will be dissemi-nated through a final report and a policybrief.

Monitoring Medicare Hospital Outpatient Payments:Trends and Evidence of Impacts of Payment Policy

NORC Walsh Center for Rural Health AnalysisExpected completion date: September 2005

Principal Investigator: Curt D. Mueller, Ph.D., 202-887-2356 [email protected]


Under the new outpatient prospectivepayment system (OPPS), outpatientdepartments that face relatively high costsof producing certain services receivepayments which may be less than theindividual facility’s costs. By contrast, anumber of small rural hospitals arecurrently exempt from OPPS and are paid

on a cost-basis, such as critical accesshospitals (CAHs) and sole communityhospitals (SCHs). In contrast to OPPSfacilities, CAHs and SCHs are expected toreceive payments that more closelyapproximate costs on average. Thepurposes of this project are to documentrecent trends in the provision of Medicare


hospital outpatient services under boththe new outpatient prospective paymentsystem (OPPS) and cost-based (CB)mechanism used for critical accesshospitals, and to assess evidence on theimpacts of Medicare OPPS on Medicareand total outpatient revenue.

Research questions to be addressedinclude the following:■ What are characteristics of the supply-side of the market for hospital outpatientdepartment services, and how is thesupply-side changing in rural areas?■ How has Medicare’s outpatientpayment policy affected provision ofoutpatient services?■ What have hospitals done to helpprepare for OPPS?

Data sources for this project includeMedicare Cost Reports, the AmericanHospital Association’s 2000 and 2002surveys, and the Area Resources File(ARF), and qualitative informationobtained from selected hospitals.Products will include a working paperthat presents descriptive statistics andempirical results informed by discussionswith administrators and a policy briefthat summarizes analysis of outpatientrevenue and trends and evidence onimpacts of outpatient payment policy onrural facilities.

National Study of Home Health Care Access in Rural AmericaUniversity of Minnesota Rural Health Research CenterExpected completion date: May 2005Principal Investigator: Beth Virnig, Ph.D., 612-624-4425 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will develop home healthcare service areas that will allow for themeasurement of access to home healthcare for rural Medicare beneficiaries whodie of cancer, and recommend options forincreasing access to home health care inunderserved rural areas. Additionally, theproject will map and estimate theproportion of the population served byhome health care agencies providing

limited availability to such treatments,and recommend options for improvingaccess to these symptom managementoptions for patients with cancer. Finalproducts will include a map of homehealth service areas and a reportanalyzing the home health and hospiceservice areas.

Medicare ■ �

National Study of Rural-Urban Differencesin Use of Home Oxygen for

Chronic Obstructive Lung Disease:Are Rural Medicare Beneficiaries Disadvantaged?

WWAMI Rural Health Research CenterExpected completion date: January 2005

Contact Person: L. Gary Hart, Ph.D., 206-685-0402 or [email protected], along withLeighton Chan, M.D., from CMS Region X


Home oxygen has been clinically shownto be beneficial to patients with chronicobstructive pulmonary disease (COPD),who cannot otherwise maintain sufficientlevels of oxygen in their body.

To understand disparities in careamong rural and urban Medicarebeneficiaries, data from Medicare’sDurable Medical Equipment (DME) fileswere used to assess rural/urban variationin the home use of supplemental oxygen.

The project researched the followinghypotheses:■ Significant rural/urban variation in

the use of home oxygen equipmentand supplies occurs within the UnitedStates

■ Home oxygen use will be directlyproportional to population density inthe areas where patients live

■ Beneficiaries in rural areas will haveless access to specialists who prescribesupplemental oxygen.

In addition, the relationships betweenage, race, and income on the use of sup-plemental oxygen were explored. Aretrospective cohort study wasperformed, examining Medicarebeneficiaries (5% random sample) whowere admitted to the hospital with aprimary diagnosis of COPD oremphysema in 1999. Rural status wasdetermined by linking the beneficiary zipcode to its Rural-Urban Commuting AreaCode (RUCA). A working paper and aone-page policy brief will be produced.

Nationwide Analysis of New Entrantsinto Medicare+Choice Demonstrations

RUPRI Center for Rural Health Policy AnalysisExpected completion date: June 2005

Principal Investigator: Keith J. Mueller, Ph.D., 402-559-4318 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will examine the effects ofrecent changes in the Medicare+Choice(M+C) program on enrollment in ruralareas and on activities of rural-basedhealth plans. Recognizing that closed-panel and staff-model health maintenanceorganizations (HMOs) are not practical inmuch of rural America, and that ProviderSponsored Organizations (PSOs) have byand large not been attractive to provider

networks, the Centers for Medicare &Medicaid Services (CMS) created ademonstration program to test theassumption that Preferred ProviderOrganizations (PPOs) could gain afoothold in many regions of the country.The 33 new Medicare plans in 23 stateswere announced in August 2002, withenrollment to begin in January 2003.


Post-Acute Care: A Rural and Urban ComparisonNORC Walsh Center for Rural Health AnalysisExpected completion date: December 2004Principal Investigator: Janet P. Sutton, Ph.D., 301-951-5070 or [email protected]: Federal Office of Rural Health Policy, HRSA

One-quarter of Medicare beneficiariesdischarged from an acute hospital aredischarged with post-acute care services.This multi-phase analysis examinedwhether discharge patterns for and use ofpost-acute care services by rural andurban hospitalized Medicare beneficiariesdiffer and, if they do, what the sources areof these different patterns. Claims datafrom the 2000-2001 Medicare StandardAnalytical Files (SAF) were used toexamine rural and urban patterns of post-acute placement in a Skilled NursingFacility (SNF), medical rehabilitationfacility, or home care following dischargefrom an acute hospital. A limited numberof diagnoses (including hip fractures,chronic obstructive pulmonary disease,and stroke) were selected for which post-acute care is typically required and forwhich care is often rendered in multiplepost-acute settings. Using patient leveldata, episodes of care were constructedfor those individuals who werehospitalized in the first three months of

the calendar year. The post-acute recordsfrom the corresponding home health,physician, and SNF SAFs for thesebeneficiaries were extracted. Claims dataare supplemented with county-levelprovider supply measures from the AreaResource File and Medicare’s Provider ofServices files.

In the first phase of this study,descriptive statistics were used todetermine whether there were anystatistically signficant rural/urbandifferences in utilization of post-acuteservices, as measured by the averagenumber of admissions, average lengths ofstay or average units of services received,or number of admissions. Separateanalyses were conducted for each type ofpost-acute setting as well as for eachdiagnostic group. In the second phase ofthe study, the focus was on substitution ofcare across different post-acute caresettings and the patterns of use ofmultiple post-acute settings within aspecific episode of care.

This project is designed to explore thedecisions of health plans (to entermarkets) and beneficiaries (to enroll inplans). Researchers working on thisproject will continue an earlier RUPRICenter project that reported ruralenrollment in M+C plans and willreplicate an earlier design of case studies

to explore the reasons plans are active inrural areas and why they may or may notbe successful.

A policy paper and two policy briefswill be produced.

Medicare ■ �

Urban and Rural Differences in Access to Care and Treatment forMedicare Beneficiaries with Cancer

Rand CorporationExpected completion date: August 2005

Principal Investigator: Lisa R. Shugarman, Ph.D., 310-393-0411 x 7701 or [email protected]: Federal Office of Rural Health Policy, HRSA

This study builds upon work addressingdifferences in the quality of cancer careacross populations. The literature on thequality of cancer care generally, and theliterature exploring differences in theincidence of cancer and outcomes of careprovided to cancer patients based onselected socio-demographiccharacteristics (e.g., gender, age, race,income or socio-economic status) is large;however, little is known about thedifferences in the diagnosis, treatmentand outcomes of care for cancer patientsacross urban and rural regions of thecountry.

The overall goals of this project are to:■ Investigate hypothesized

relationships between urban andrural residence and a range ofoutcomes of care for Medicarebeneficiaries with cancer

■ Explicitly evaluate selected marketand provider supplycharacteristics of selected regionsthrough which geographicvariations are hypothesized toaffect health outcomes

■ Assess differences in personal(e.g., gender, race) and community(e.g., poverty rate) characteristicsin observed patterns of associationwithin and across urban and ruralregions

■ Explore how changes in thesupply of providers in urban andrural areas over time may haveinfluenced the outcomes ofinterest.

Using Surveillance, Epidemiology,and End Results (SEER) data merged withMedicare claims data available from theCenters for Medicare and MedicaidServices (CMS), project staff will examinea series of models testing hypothesizedrelationships between individual andcommunity characteristics and theoutcomes of interest (timing of diagnosis,timing from diagnosis to first treatment,disease-free survival, overall survival).First, urban and rural differences will beestimated in the incidence and prevalenceof disease, as well as the treatment,follow-up, and mortality/survival.Second, personal and communitycharacteristics (including providersupply) will be explored in order toexplain urban and rural differences inthese selected measures. Finally, changesin the supply of providers will beexamined to determine the extent thesechanges have resulted in changes in theoutcomes of care over time across urbanand rural regions.


V

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Public Health ■ �

Pharmaceutical Data Validity in Estimating Rural HealthMississippi State University

Expected completion date: August 2005Principal Investigator: Ronald Cossman, Ph.D., 662-325-4801 or [email protected]


Chronic diseases account for more than60% of total medical expenditures in theU.S., and 70% of all deaths. Yet, morbidityrates for the vast majority of chronicillnesses are not reported, and thosereportable diseases (e.g., cancer,tuberculosis, etc.) are not reported at thecounty level. Thus there is no means formapping the prevalence rates of chronicdiseases in rural areas. This project willuse a proprietary data base of drugprescriptions filled in the U.S. as a proxyfor prevalence of both the top mortality-causing diseases (e.g., heart attack, stroke,

asthma and diabetes), as well as selectednon-fatal illnesses that have disabilityimplications (e.g., sinusitis, arthritis,ADHD and chronic pain). This projectwill allow for the quantification ofvariation in morbidity (via prescriptionuse) across rural areas; identify locationsthat might be at risk for stunted economicdevelopment due to high levels of chronicillness in the working population; andpotentially lead to the development of avalid and reliable measure of county-levelrates of chronic illness using prescriptiondata as a proxy.

VPUBLIC HEALTH

Public Health System Performance Measurement:Are Standards Applicable to Rural Communities?

NORC Walsh Center for Rural Health AnalysisExpected completion date: December 2004

Principal Investigator: Claudia Schur, Ph.D., 301-951-5070 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project aims to increaseunderstanding of how public healthgovernance affects the structure of publichealth services, and how this in turninfluences the strategies adopted formeeting community public health needsin rural areas.

Since the early 1990s, public healthadvocates have been concerned abouthow a national health care plan mightincorporate or co-exist with public healthcare functions.

A list of ten essential servicesof public health was developed by theCDC. Recently, work has focused onformulating a systematic strategy formeasuring public health practice withrespect to these services at both the state

and local levels. Many “public health”functions are conducted, at least in part,by hospitals, private practice physicians,and community groups as well as avariety of entities that are not focusedstrictly on health. The division ofresponsibilities in a community mayresult from state regulation, historicalpractice, local political dynamics, or otherfactors. With respect to public healthpractice, public health systems in ruralareas differ from those in urban areas interms of scope of services and functions,in part due to differences in the level ofresources available (resulting in lowerstaffing levels and fewer specializedcapabilities) and in part based on


geography (i.e., the size of the areacovered and geographic isolation). Howthese distinctly rural features combinewith state public health governance andlocal features to meet local public healthneeds is not well understood.

The Walsh Center conducted a seriesof case studies of several states to addressthe following policy questions:■ What are the different state-mandated

structures for delivery of public healthservices?

■ How do these structures differentiallyaffect rural and urban areas within astate?

■ How do different structures influence thetype of services provided and the mix ofresources available to rural communities?

■ How does the structure affect the range ofentities providing public health services(e.g., community health centers, hospitals,community groups)?

■ What are the differences among ruralcommunities that affect their ability tofunction effectively over time with respectto public health function?

A report and policy brief will be preparedfor distribution to policymakers and personson the Center mailing list.

Rural Public Health Structure and InfrastructureKansas Health InstituteExpected completion date: August 2005Principal Investigator: Anthony Wellever, M.A., 785-233-5443 or [email protected]: Federal Office of Rural Health Policy, HRSA

The organizational structure of localhealth departments (LHDs) is key to theireffectiveness. Resource shortages in somerural areas may compromise somecomponents of structure, leading to pooroutcomes. Poor performance may beremedied by rural LHD networking,mergers, or regionalization, tocompensate for structural deficiencies.Which components of LHD structuremake the largest contribution to outcomesis not known. This project is intended togenerate hypotheses about therelationship of LHD structure andinfrastructure to performance. It is hopedthat subsequent researchers will use thestructural characteristics identified in thisproject to more fully describe rural LHDsthrough survey research and to establishrelationships between structure andvarious measures of local public healthdepartment performance.

Investigators will conduct site visits tosix states. In each of the six, investigatorswill visit the office in the stateDepartment of Health or its equivalentresponsible for LHD management,coordination, or liaison and interview the

chief administrative officer for LHDaffairs. In each of the six states, site visitsto two rural LHDs will also be conducted.LHD sites will be selected to reflectdifferences in governance (i.e. centralized,decentralized, mixed model), primaryindustries, managed care penetration, andpoverty to name a few. Using standardprotocols, the administrator of the LHD, amember of the governing board, themedical director, and others will beinterviewed. Documents also will becollected from the sites (e.g., budgets,staffing tables, contracts, studies) duringthe visit. Data collected before, during,and following the site visits will beanalyzed and findings reported inindividual case studies and a summativereport of cross-cutting themes andstructural characteristics of LHDs byenvironmental attributes such aspopulation served, and relationship withstate government. A list of characteristicsof LHD structure will be produced thatare sufficiently common acrossgeography, rurality, and governance toserve as independent variables for futurestudies of LHD performance.

Quality ■ �

VQUALITY

Assessment of Small Rural Hospital Activities toReport Medication Errors

RUPRI Center for Rural Health Policy AnalysisExpected completion date: August 2005

Principal Investigator: Keith J. Mueller, Ph.D., 402-559-4318 or [email protected]: Federal Office of Rural Health Policy, HRSA

and CAHs (and peer groups of non-CAHSRHs with more than 25 beds). At the locallevel, this research can provideadministrators, governing boards, andproviders with a rationale to buildcollaborative relationships with peers,network hospitals, academic medical centers,and national error reporting systems.Aggregate error reporting systems canprovide the means to monitor the outcome ofpatient safety in the nation’s smallesthospitals as the structure and process ofmedication use changes through suchpractices as bar coding, automateddispensing machines, and telepharmacy.

Products of this research will include apolicy brief describing the medication useprocess in SRHs with emphasis onincorporation of safe medication practicesdespite limited resources, a policy paperdiscussing unique characteristics of SRHsthat affect how projects to improve patientsafety should be approached, a policy briefsummarizing the results of hypothesestesting and implications for federal policyinitiatives and private sector activitiesdesigned to enhance patient safety andquality improvement, and scholarly productsfor dissemination at professional meetings.

This research will determine how smallrural hospitals (SRHs) have responded tothe environmental pressure to improvepatient safety and quality byimplementing safe medication practicesand reporting and monitoring medicationerrors. SRHs will be surveyed, in tworandom samples. For both Critical AccessHospitals (CAHs) and SRHs, theestimates of interest are the proportionthat employ a full time pharmacist, theproportion that use automation indispensing and administeringmedications, and the proportion that usesafe medication practices.

This research will be of interest todecision makers at national, state, andlocal levels. At the national level, adescription of the consequences of limitedpharmacy support on medication use andmedication error reporting in SRHs canprovide the rationale for leveragingtechnological innovations such astelepharmacy to achieve more equitablehospital medication use systems for ruralpopulations. At the state level, anunderstanding of the consequences oflimited pharmacy support for medicationerror reporting behavior will provide acontext for the importance of establishingrelationships between network hospitals


Examining the Applicability of AHRQ’s Inpatient Quality Indicatorsto Rural Hospitals and the Implications of the Relationship Betweenthe Indicators and Financial Measures for Medicare Payment PoliciesRUPRI Center for Rural Health Policy AnalysisExpected completion date: August 2005Principal Investigator: Li-Wu Chen, Ph.D., 402-559-7113 or [email protected]: Federal Office of Rural Health Policy, HRSA

Since the populations served by ruralhospitals and urban hospitals are quitedifferent, their quality concerns may alsobe different. As standardized qualitymeasures for hospital reporting aredeveloped, it is critical that differencesbetween rural hospitals and urbanhospitals are considered. This study willdetermine whether the Agency forHealthcare Research and Quality’s(AHRQ’s) inpatient quality indicators(IQIs), which were developed withoutconsideration of an urban/ruraldifference, are appropriate for use in ruralhospitals.

This study will be divided into twocomponents. The first component willinvestigate how AHRQ’s IQIs can be

applied to rural hospitals. The secondcomponent will explore the application ofAHRQ’s IQIs in answering relevantpolicy questions. The findings of thisstudy are expected to informpolicymakers about how standardizedquality measures can be adjusted for ruralhospitals and to provide usefulinformation about the relationshipbetween standardized quality measuresand financial performance among ruralhospitals, information that can be usedwhen policymakers try to incorporate aquality element into Medicare’s paymentsystem.

Products of this research will includepolicy briefs and journal manuscripts.

Improvement in the Quality of Care for Acute Myocardial Infarction(AMI): Have Rural Hospitals Followed National Trends?WWAMI Rural Health Research CenterExpected completion date: January 2005Principal Investigator: Laura-Mae Baldwin, M.D., M.P.H., 206-685-4799 or [email protected]: Federal Office of Rural Health Policy, with computer access time and data donated by CMS

AMI is one of the leading causes of deathin the United States and a common causefor admission to U.S. hospitals. AMIrequires immediate care in a hospitalsetting to minimize morbidity andmortality. In rural hospital settings,transport of patients with AMI to urbansettings could result in delays in care.Some of the most effective and immediatetreatments for AMI require only basicintravenous access and should be equallyaccessible in rural and urban hospitals.

This project determined whetheroverall improvements in the quality ofcare for AMI among Medicare patientshave taken place in both rural and urbanhospital settings. This study had threeprimary hypotheses:■ Quality of care for AMI has improved

in all types of rural hospital (large,small, and remote small) between1995 and 2000

■ The rate of improvement in thequality of care for AMI in ruralhospitals lags behind that in urbanhospitals

Quality ■ ��

Rates of AMI guidelines adherence by thethree types of rural and urban hospitalswere calculated for these hospitalsnationally, by region, division, and statein the two time periods. A working paperwill be produced, and an article will besubmitted for publication to a peer-reviewed journal.

Pay for Performance and Quality Improvement in Rural HospitalsUpper Midwest Rural Health Research Center

Expected completion date: September 2005Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected]


This project has three primarypurposes:■ To estimate the impact on rural

hospitals in the U.S. of a pay-for-performance (PFP) program similar tothe CMS-sponsored Premier, Inc.Hospital Quality IncentiveDemonstration

■ To complete a synthesis of the majorfactors that will influence theinclusion of rural hospitals in PFPprograms

■ To make recommendations for thedesign of PFP programs that willappropriately reward rural hospitalsfor improving quality.

This project will empirically assesshow rural hospitals in the U.S. would farefinancially (i.e. receive bonus payments,

be eligible for reduced DRG payments) ifthey participated in the CMS-sponsoredPremier HQID; identify and thoroughlyexamine the key factors that facilitate orconstrain rural hospital participation inpay for performance programs; anddescribe options for the design of pay forperformance programs that are relevantfor rural hospitals that seek qualityimprovement. This study will use datafrom several sources, including data onthe CMS 7th Scope of Work measures anddata from a telephone survey of keyrepresentatives from major stakeholders(e.g. CMS, Premier, AHA, rural hospitals,rural relevant physician associations)involved with PFP projects.

■ The smallest and most remote ruralhospitals demonstrated lesserimprovements in the quality of carefor AMI than larger rural hospitals.

This study included Medicarebeneficiaries 65 years and older with anAMI confirmed by specific medicalcriteria who were directly admitted forthe AMI care (rather than transferred).


Refining and Field Testing a Relevant Setof Quality Measures for Rural HospitalsUniversity of Minnesota Rural Health Research CenterExpected completion date: June 2005Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected]: Centers for Medicare and Medicaid Services

This project has the followingobjectives:■ To refine the draft set of relevant

quality measures for ruralhospitals through their review bya national expert panel andleading national qualityorganizations

■ To develop additional measuresnot included in existing qualitymeasurement systems that arerelevant to rural hospitals (e.g.,measures related to the triage,referral, and transport of patients)

■ To field test the revised set ofrelevant quality measures for ruralhospitals in collaboration with twoQuality Improvement

Organizations (QIOs); and toassess strategies for how QIOs,CMS, and rural hospitals can usethe above quality measurementdata to improve quality forMedicare beneficiaries in ruralhospitals.

Key issues to be considered in thefield test include ease of datacollection; perceived usefulness of thedata to the hospital staff; use of thedata by the hospital and the QIOs forquality improvement within thehospital; and use of the data by CMSfor external reporting needs.

Rural Quality Improvement Focus on DiabetesRUPRI Center for Rural Health Policy AnalysisExpected completion date: April 2005Principal Investigator: J. Patrick Hart, Ph.D. 402-559-8964 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will examine the policyimplications of current approaches,characteristics, and effectiveness ofdiabetes care management and qualityimprovement programs in rural areas.Diabetes is a well-understood diseasefor which there has been a reasonablylarge amount of programdevelopment in rural areas involvingcare management, self-management,and prevention, or combinations ofthese elements. Diabetes programsrepresent, therefore, a sound startingpoint for understanding the ruralcontext, process, structure, barriers,and operational and performanceresults of chronic disease management

and quality improvement programmingin rural areas.

This project will focus specifically ondiabetes care management and qualityimprovement programming in rural areasto better understand the adaptability andpolicy implications of using chronic carecoordination and other models in a ruralenvironment. The following hypotheseswill be researched:■ Early adoption and success are more

likely when there is active leadership,existing collaborative relationshipssuch as alliances and networks, stronglinks to community-based resourcesneeded for care management, activeparticipation of the Quality

Quality ■ ��

Improvement Organization, andsupport from state professionalassociations

■ The greater the distance that diabetescare programs are from urban

counties the less likely the use ofcertified diabetes education and theless likely the program to besustained.

Successful Implementation of Medication Safety Initiatives in RuralHospitals: The Role of Pharmacists and Technology

Upper Midwest Rural Health Research CenterExpected completion date: September 2005

Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected] Person: Michelle Casey, M.S., 612-627-4251 or [email protected]


This project will assess the capacity ofrural hospitals to implement medicationsafety practices that reduce the likelihoodof serious adverse drug events, andidentify factors that facilitate successfulimplementation of medication safetypractices in rural hospitals. The projectwill focus on two key aspects of ruralhospitals’ capacity to implementmedication safety initiatives: pharmaciststaffing and the availability of technology.

This project is national in scope andwill have relevance for policymaking atthe federal, state and local levels. Theproject will include analysis of primarydata from a phone survey of a national

sample of rural hospitals and secondarydata from the AHA Annual Survey andArea Resource File. The telephone surveywill be developed based on a review ofthe literature on medication safetypractices in hospitals and input from arural hospital pharmacist advisory group.The survey will include questionsregarding pharmacy staffing, the use ofmedication safety technology, and factorsthat have influenced successfulimplementation of medication safetypractices in the hospital. A report on theproject findings will be completed by theend of September 2005.


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Racial and Ethnic Populations ■ ��

Diabetes and Hypertension in Rural HispanicsSouth Carolina Rural Health Research Center

Expected completion date: January 2005Principal Investigator: Arch Mainous, Ph.D., 843-792-6986 or [email protected]


VRACIAL AND ETHNIC POPULATIONS

This project examined the similarities anddifferences between rural and urbanHispanic and Caucasian adults diagnosedwith diabetes mellitus and hypertension.

Diabetes mellitus and hypertensionare common and potentially disablingchronic diseases. Rural and minoritypopulations have historically hadproblems accessing care and areparticularly vulnerable to theconsequences of lower access to care.Despite the evidence from the early 1990sthat diabetes is more prevalent amongHispanics and that rural populations havebarriers to care that may negativelyimpact health care services for patientswith diabetes, it is unclear whether ruralHispanics are disproportionately affected.Further, in comparison to urban residentsthe extent of decreased services may be aparticular issue for timely diagnosis ofdiabetes in rural Hispanic patients.Language barriers may have particular

implications for providing care in thispopulation. Addressing these issues hassignificant implications for rural healthpolicy and the distribution of manpowerand resources.The project had two specific objectives:■ To examine the similarities and

differences between rural Hispanicand Caucasian adults diagnosed withdiabetes mellitus and hypertension aswell as urban Hispanic and Caucasianadults in terms of diabetes and bloodpressure control and complicationsusing the 1999-2000 National Healthand Nutrition Examination Survey(NHANES)

■ To examine the prevalence ofundetected diabetes mellitus andhypertension among rural Hispanics,rural Caucasians, urban Hispanicsand urban Caucasians using theNHANES.

How Rural Hospitals Are Meeting the Needs ofLimited English Proficiency Patients


Principal Investigator: Deborah Parra-Medina, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

There were 37.4 million Latinos in theUnited States in 2002, representing 13.3 %of the U.S. population, thus becoming thelargest minority in the United States.Latinos and other immigrants who arelimited English proficient (LEP)encounter multiple barriers accessing

health care. On August 11, 2000 PresidentClinton issued the executive order 13166(See 65 Fed. Reg. 50121), entitled: “Im-proving Access to Services for PersonsWith Limited English Proficiency.” After aprocess of public comment and input, theHHS Office of Minority Health issued the


National Standards on Culturally andLinguistically Appropriate Services inHealth Care (CLAS Standards) on Decem-ber 22, 2000 (See 65 Fed. Reg. 80865).

There are few studies that focus on theability of rural hospitals to comply withCLAS standards. This project will surveyrural hospitals in order to:■ Determine the extent to which rural

hospitals in areas of high Hispanicpopulation growth have implementedplans for compliance with the DHHSLEP regulations

■ Describe the difficulties rural hospitalsmust overcome in order to provideculturally and linguistically appropriatehealth care to Hispanic clients

■ Ascertain the translation techniquesmost commonly used by rural hospitalsin high Hispanic population growthcounties

■ Describe the approaches that ruralhospitals perceive to be most effectivefor the provision of culturallycompetent health care to Hispanicclients.

Products of the survey will include atechnical report to be submitted to ORHP.In order to make this document accessibleto a practitioner audience, the report willincorporate vignettes illustrating howrural hospitals are successfully addressingthe needs of LEP patients. “Key Facts”sheets will be developed for distributionto policymakers and the public. Toaddress the academic and medicalcommunities, findings will be presentedat state and national meetings, with anemphasis on organizations servingHispanic populations. In addition,scholarly papers are anticipated, such asquality implications of oral translationtechniques currently used by ruralhospitals in high Hispanic growthcommunities, and the relationshipbetween size of Hispanic community andtranslation approaches used by ruralhospitals.

The Impact of Health Insurance Coverage on Native Elder Health:Implications for Addressing the Health Care Needs of RuralAmerican Indian EldersUpper Midwest Rural Health Research CenterExpected completion date: September 2005Principal Investigator: Ira Moscovice, Ph.D., 612-624-8618 or [email protected] Person: Alana Knudson, Ph.D., 701-777-4205 or [email protected] Jacque Gray, Ph.D., 701/777-0582 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will determine what types ofhealth insurance coverage rural NativeAmerican elders have and examine howdifferent types of health insurancecoverage and lack of health insurancecoverage impact access to health careservices among Native American eldersby geographic location (rural frontier,rural non-frontier and urban).

The study will address the followingresearch questions:

■ What is the rate of health insurancecoverage among Native Americanelders living in rural frontier, ruralnon-frontier and urban counties?

■ What types of health insurancecoverage do Native American eldersliving in rural frontier, rural non-frontier and urban counties have?


■ Who are the uninsured NativeAmerican elders and what is theirdemographic make-up?

■ What is the relationship betweenhealth insurance coverage, geographiclocation, key demographic factors andhealth status indicators among NativeAmerican elders?

■ What is the relationship betweenhealth insurance coverage and accessto health care services among NativeAmerican elders?

The study will analyze national datafrom Identifying Our Needs: A Survey ofElders II, a Native elder social and healthneeds assessment project conducted bythe NRCNAA in collaboration with tribesthroughout the country. To allowanalyses by rural, frontier, and urbanlocation, the Native Elder II survey datawill be linked to Urban Influence Codevariables from the Area Resource File andfrontier variables from the Census datausing county FIPS codes.

National Trends in the Perinatal andInfant Health Care of Rural and

Urban American Indians (AIs) and Alaska Natives (ANs)WWAMI Rural Health Research CenterExpected completion date: January 2005



This project examined and comparedtrends in prenatal care and mortality ratesof rural and urban AI/AN and non-AI/AN populations in order to determine thelevel of disparity between thesepopulations. While there have beendramatic improvements in AI/ANmaternal and child health since thesemeasures were first recorded in the mid-1950s, significant disparities persistbetween AI/AN and non-AI/ANpopulations in the U.S. This studyexamined trends in prenatal care use, lowbirth weight rate, and the neonatal andpost-neonatal mortality rates in rural andurban AI/AN populations nationallybetween 1985 and 1997, and comparedthese trends in the white and African-American populations during the sametime period. Additionally, trends incauses of death for rural and urban AI/

AN populations nationally between 1985and 1997 were examined and compared tothe non-AI/AN population during thesame time period. Trends in our studymeasures for AI/AN and non-AI/ANpopulations were analyzed by Censusregion, division, and Indian HealthService (IHS) Service Areas. The studyused the National Linked Birth DeathData Set at three points in time: 1985-1987, 1989-1991, and 1995-1997, andcompared rates of inadequate prenatalcare, low birth weight, neonatal and post-neonatal death, and causes of deathbetween rural and urban AI/ANs in eachof the three time periods, as well as overtime. Rates of these same outcomemeasures are provided for white andAfrican-American populations during thesame time periods for reference.


Native Elder Care Needs Assessment: Development of a Long TermCare Planning Tool KitUniversity of North DakotaExpected completion date: January 2005Principal Investigator: Alan Allery, M.H.A., 701-777-3859 or [email protected] Person: Francine McDonald, M.P.A., 701-777-4043 or [email protected]: Federal Office of Rural Health Policy, HRSA

The objectives of this comprehensivestudy are to:■ Profile demographics of rural African

Americans by region of the U.S.■ Describe clinical problems prevalent

in rural African American populations■ Explore available health care facilities

and practitioners in rural areas■ Investigate outpatient treatment

provided to rural African Americanpopulations, by type of practitioner

■ Explore expenditures for health careamong rural African Americans, byregion of the U.S.

■ Determine barriers to care such asinsurance, provider availability, andhealth beliefs/behaviors.

Six reports have been submitted todate as part of the comprehensiveassessment of minority health, and a finalreport is underway summarizing sourcesof funding for health care among ruralminorities based on the MedicalExpenditure Panel Survey.

Rural Minority Health: A Comprehensive AssessmentSouth Carolina Rural Health Research CenterExpected completion date: August 2005Principal Investigator: Janice C. Probst, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project developed a tool kit to assisttribes with interpreting long term caredata obtained through a national NativeElder Care Needs Assessment conductedby the National Resource Center onNative American Aging at the Center forRural Health, University of North Dakota,School of Medicine and Health Sciences.A long term care planning tool kit willassist tribes in using the data to developlong term care infrastructure andcomprehensive services that respond to

local needs and services. The tool kit willalso assist rural health policymakers withidentifying the specific needs of theircommunities or population andtranslating those needs into action basedon data collected by the tribe for theirgeographic area. The tool kit will bepublished in both web based and paperformat and will be specifically gearedtowards American Indian and AlaskaNative elderly.


Tribal Long-Term Care: Barriers to Best Practices in Policy andProgramming for a National Sample of Rural TribesWest Virginia University Research Corp.Expected completion date: August 2005Principal Investigator: R. Turner Goins, Ph.D., 304-293-2081 or [email protected]: Federal Office of Rural Health Policy, HRSA

The project will examine barriersexperienced by rural American Indianand Alaska Native (AI/AN) reservationtribes in developing long term care policyand service provision, identify tribeswhich exemplify best practices in the areaof long term care policy, and documentwhat other tribes would need to know todevelop successful long term careprograms (i.e., lessons learned). Theresearch project and resultant informationwill be national in scope. This project willsurvey a nationally representative sampleof 130 federally recognized rural AI/ANtribes. To generate the list of best practicetribes, the National Coordinator of theIHS Elder Health Care Initiative will becontacted along with members of theproject’s Advisory Committee. Theseindividuals will be asked to identify tribes

with best practices and/or recommendothers who may be able to identify tribesfor this purpose. Thus, the second samplewill be a purposive sample of tribal healthboard members recruited to participate inin depth interviews. In an effort tocapture all tribes nationwide thatexemplify best practices, the purposivesample will be complete when no newtribes are recommended. In a populationas beset by health concerns as AI/ANs,the identification of barriers todeveloping needed long term care policyand programs achieves tremendousimportance. This project represents asystematic effort to improve the ability ofthe health care delivery systems torespond to the needs of disabled AI/ANs.


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Research�Policy Interface ■ �

VRESEARCH�POLICY INTERFACE

Database for Rural Health Research in ProgressMaine Rural Health Research Center

Expected completion date: August 2005Project Director: Karen B. Pearson, M.L.I.S., M.A., 207-780-4553 or [email protected]


The product of this project is a searchabledatabase of current rural health researchand policy analysis which includes allORHP-funded studies as well as researchfunded by other federal agencies, majorprivate foundations and other sources.Research dealing with the financing,organization, and/or delivery of health,mental health, and/or substance abusetreatment services in rural areas or topeople residing in rural areas is withinthe scope of this database. Rural healthresearch is also defined to include studiesof the prevalence of health, mental healthor substance abusing conditions among

rural population groups. Studies of theeffects of changes in the rural health caresystem on the rural economy, rural/urbancomparison studies, and studies of theexperiences of rural residents in receivinghealth, mental health or substance abusetreatment services are also included. Theweb site address for the database ishttp://www.rural-health.org/database.In addition, an annual publication of ruralhealth research in progress in the ORHP-funded centers is produced anddisseminated to policymakers.

Evaluating Need for Assistance Criteria and Weighting of OverallCriteria in the Requirements of Funding New Start and Grant

Applications for Health CentersNorth Carolina Rural Health Research Program

Expected completion date: March 2005Principal Investigator: Thomas Ricketts, Ph.D., 919-966-5541 or [email protected]

Funder: Bureau of Primary Health Care, HRSA

Providers of services who wish to becomepart of, or continue to receive fundingthrough, the health centers program mustapply through the Bureau of PrimaryHealth Care (the Bureau) as part of astringent application process. A keycomponent of the application is thecompletion of a Need for Assistance(NFA) worksheet that represents the firstphase of a multi-tiered screening andaward process. This project will extendand enhance work done previously forthe Bureau by examining the current andproposed changes to the Need for

Assistance (NFA) criteria. Data submittedby applicants for assistance through theBureau will be examined, and then theeffects of optional weighting and scalingof the data for the development of scoresthat allow for ranking and comparison ofapplications will be tested. The projectwill support the review and decisionmaking process the Bureau uses to fundand support community-based programs.The project will answer two keyquestions: Does the modifiedmethodology for the NFA proposed bythe Sheps Center under prior contract


work accurately reflect and improve theassessment of relative need of differentapplicants? Are the review criteriaproperly selected and weightedappropriately to help assure that theHealth Center program accurately andeffectively targets the neediest areas?Statistical evaluation of the NFA datafrom the entire FY 2004 New Start andExpansion applications (1st Round) will beconducted. These data will besupplemented by data sets developed to

support the development and testing ofrevised HPSA-MUA, data collected insupport of the Data Warehouse projectwithin HRSA, as well as shared dataprovided by the Primary Care ServiceArea Project and in house data setsmaintained by the Sheps Center. Findingswill be presented in a final report to besubmitted to the Project Officer.

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Service Delivery ■ �

Access to Cancer Services forRural Colorectal Cancer Medicare Patients:

A Multi-State StudyWWAMI Rural Health Research CenterExpected completion date: January 2005



This study examined a comprehensivedatabase to quantify the distance andaccess to four types of cancer services in asample of rural, Medicare-insured,colorectal cancer (CRC) patients ofdifferent racial and ethnic groups. CRC isthe second most common cause of cancerdeath in the U.S., and disproportionatelyimpacts racial and ethnic minorities.Cancer care requires a sophisticated set ofsurgical and medical resources morecommon in large urban settings. Greaterproportions of rural cancer patients are

diagnosed at later stages than urbanpatients and are less likely than urbanpatients to receive state-of-the-art cancertreatments. The database linksSurveillance Epidemiology and EndResults (SEER) cancer registry, Medicareclaims, AMA Masterfile, and AmericanHospital Association data. This studywill inform future work designed tounderstand discrepancies in cancerservice use by the rural elderly indifferent racial and ethnic groups.

VSERVICE DELIVERY

Describing Geographic Access to Physicians in Rural AmericaUsing Statistical Applications in GIS

North Carolina Rural Health Research and Policy Analysis CenterExpected completion date: August 2005

Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or [email protected] Person: Thomas Ricketts, Ph.D., 919-966-5541 or [email protected]


This study will use a geographicapproach to assess the influence ofdistance and travel time on thedistribution of physicians in ruralAmerica. The Medicare ModernizationAct contains financial provisions aimed atchanging the distribution of physicians,and called for a revision in thedetermination of areas eligible forMedicare bonus payment support. Therecontinues to be a need to accuratelycharacterize primary care distribution andmeasure access to care for rural places.The goal of this work is to improve our

measures of access by identifying theextent to which cross border resources canbe considered in indices of access.

There are four specific goals for theproposed research:■ To identify more accurately how

supply in adjacent areas can be usedto adjust ratios or to characterizeoverall geographic access

■ To analyze county boundaries todetermine where they are effectiveproxies for service areas for shortagedetermination and how to make bestuse of the Primary Care Service Areas


(PCSAs) developed by the Dartmouthand the Medical College of Virginiateam in the assessment of geographicaccess to care

■ To repeat analyses that characterizethe distribution of physicians as moreadequate using more current data andoptional assumptions that capture therange of possible policy options

■ To develop summary indices ofsupply for small areas, regional areas,and guidance for using smoothedsupply estimate.

Findings will be presented in a reportpresenting a more accurate representationof the distribution of physicians across thenation and the access to those physiciansfor the rural population. An article for apeer-reviewed journal and a findingsbrief will be produced describing ourfindings of national physician availabilityand distribution, considering the urban-rural gradient in particular.

Do Communities Make a Difference in Access?A National StudyRUPRI Center for Rural Health Policy AnalysisExpected completion date: June 2005Principal Investigator: Timothy D. McBride, Ph.D., 314-977-4094 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will examine the effect ofcommunity-level resources on anindividual’s access to health care,particularly whether urban and ruralindividuals’ access to health care differs,given community differences. If ruralresidents lack access to appropriate andneeded health care services as a functionof where they live, they may have lowerhealth care utilization and, therefore,diminished outcomes. Lack of access maylead to a lack of preventive care, delays inseeking needed care, and otherinappropriate health care use.Community-level variables may limithealth care access for low-income people,especially in rural areas. Community-level resources affect an individual’s

ability to use health care resources if theinstitutions that deliver health care are notaccessible.

This project will use empirical research,differentiated at the urban and rural levels, totest the following hypotheses:■ Access to care is affected by enabling,

predisposing, and need characteristics ofthe individual, but also by communitydemand, community support communitystructure variables

■ Community-level variables will play amore significant role in ruralcommunities.

A policy paper and policy brief will beproduced based on the findings.

Service Delivery ■ �

Rural Access and State Loan Repayment for DentistsNational Conference of State Legislatures

Expected completion date: June 2005Principal Investigator: Shelly Gehshan, M.P.P., 202-624-3586 or [email protected]


Over the past five years, a number ofstates have turned to an idea that hasbeen successful at the national level butlittle used by states, namely state loanrepayment programs for dentists with aservice requirement. However, little isknown about these programs for dentists,in terms of their structure, size,requirements, and results. Findings fromthis study could be used by state offices ofrural health and oral health to developprograms that are effective in increasingthe supply of dentists in rural areas.

This project will identify and evaluatethe effectiveness of these programs fordentists on improving access to ruralhealth care. This study will establishbaseline information about theseprograms that can be used by states todesign and tailor similar programs forrural access.

This study hypothesizes that stateloan repayment programs for dentists arean effective strategy in improving accessto dental care in rural areas. A study of all50 states will determine the following:■ The number of states which have state

loan repayment programs for dentists■ The requirements of each program,

and what do dentists receive in return

■ The number of dentists currentlypracticing in rural areas with stateloan repayment program support andwhat impact they are having on access

■ The long-term results of theseprograms in terms of retention ofprogram participants in rural areas

■ How the costs of these programscompare with other strategies thathave a similar target such as mobilevans.

This study will also give states bench-marks for comparison and informationabout the long-term effects and aquestionnaire to use in tracking retentionof loan repayment recipients. To guide thestudy, NCSL will convene periodically bytelephone conference a small advisorypanel of state rural oral health experts.The panel will include officials from astate office of rural health, oral health,and Medicaid dental program as well as acurrent or former rural dentist andrepresentative of a state dentalassociation. Panel members will be askedto review telephone interview questions,questions for participating dentists andprovide expert commentary on researchresults.

Rural Safety Net Provision and Hospital Care in 10 StatesGeorgia Health Policy Center

Principal Investigator: Patricia Ketsche, M.B.A., Ph.D., 404-651-2993 or [email protected] completion date: September 2005


This project will evaluate whether accessto primary care is more effective atimproving health and reducing cost inrural than urban markets, and identify thecharacteristics of communities which

determine the effectiveness of primary careaccess.

There is substantial evidence that accessto primary and preventive services canreduce the necessity for hospital care and


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hence indicate improved health.Reductions in unnecessary hospital carefor the uninsured are important for ruralhospitals concerned about costcontainment.

This project will use a cross-sectionalanalysis of secondary data from multiplesources to compare the effectiveness ofrural and urban publicly funded primarycare in 10 diverse states. This research willinform policy relating to the best balanceof funding between access provisionthrough public clinics and coverageexpansion to reduce the burden of

uncompensated care on financiallystrained rural hospitals. This study willalso help identify those communitycharacteristics such as populationdemographics, income levels, numbersand types of private providers, and thedegree of organization of the privatemarket that contribute to greatereffectiveness of public primary careaccess.

Special Needs of Women and Children ■ �

VSPECIAL NEEDS OF WOMEN AND CHILDREN

Mental Health Risk Factors, Unmet Needsand Provider Availability for Rural Children

South Carolina Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: Charity G. Moore, Ph.D., 803-251-6317 or [email protected]: Federal Office of Rural Health Policy, HRSA

Accurate measures of childhoodvulnerability to mental health problemscan help guide public policy that allocatesresources for mental health care tospecific populations, including fundingand human resources allocated to ruralcommunity mental health centers. Thisstudy will add to the current knowledgeof unmet mental health need for ruralchildren, using data from the 2001National Health Interview Survey(NHIS). The 2001 NHIS included, inaddition to questions concerning

diagnosed mental health problems,administration of the Strengths andDifficulties Questionnaire (SDQ). TheSDQ detects sub-clinical mental healthproblems, including emotional problems,conduct problems, hyperactive behavior,peer relationship difficulties, and lack ofprosocial behavior. This study examinedthe prevalence of sub-clinical mentalhealth problems in rural children,assessed risk factors associated withproblems in children, and assessed theinfluence of local provider availability onhealthcare provider contact.

Poverty, Parental Stress, and Violent Disagreementsin the Home Among Rural Families


Principal Investigator: Charity G. Moore, Ph.D., 803-251-6317 [email protected]


Studies suggest that between 3.3 and 10million children witness some form ofdomestic violence annually. Childrenwitnessing domestic violence are morelikely to have emotional/ behavioralproblems and be in abusive relationshipsin adulthood regardless of co-occurringchild maltreatment. A recent ORHPreport noted that “. . . the alreadysignificant problems of battered womenare likely exacerbated by rural factors.”(http://ruralhealth.hrsa.gov/pub/domviol.html).

The study will use the NationalSurvey of Children’s Health (NSCH), a

nationally representative telephone survey, toaddress the following hypotheses:■ The prevalence of poverty, parental stress

and violent disagreements in the homeincrease with rurality

■ Economic hardships at the individual andcommunity levels are associated withincreased parental stress. We hypothesizethe effects of economic hardships will bemagnified in rural families and decreasedfor African American, Hispanic, andother race/ethnicity families

■ Parental stress will be positivelyassociated with rates of violent


Quality of Women’s Care in Rural Health Clinics:A National AnalysisEast Tennessee State UniversityExpected completion date: August 2005Principal Investigator: Joellen B. Edwards, Ph.D., RN, 423-439-4055 or [email protected]: Federal Office of Rural Health Policy, HRSA

Most initiatives to improve the quality ofhealth care are based on services providedin urban, high-volume inpatient centers.Little is known about the quality of healthcare in rural primary care settings. Onetype of primary care setting of interest tolegislators, regulators, and the Office ofRural Health Policy are certified ruralhealth clinics (RHCs). RHCs receive cost-based reimbursement for care of Medicareand, in most states, Medicaid popula-tions, and are the most numerous safetynet providers in rural areas. The BalancedBudget Act of 1997 requires that thesesites establish quality assurance andperformance improvement programs inthe near future. However, a nationalstudy of quality of care in RHCs has notbeen completed. One indicator of qualityin primary care is the measurement of the

level of health screening proceduresreceived by patients. Rural womenexperience higher rates of illness thanurban women, yet receive fewer life-saving screening procedures. Rates ofscreening interventions are important inmeasuring the quality of women’s healthin RHCs and other settings.

This study will analyze the rates atwhich women patients receive fiverecommended preventive screeninginterventions in a national, geographi-cally stratified random sample of RHCs.Results of the analysis will be used toderive implications for rural health policy.

disagreements in the home; thisrelationship will be consistent acrossall race/ethnicity groups

■ Parental stress and violentdisagreements in the home will bepositively associated with presence ofmental health problems in children.

As with other SCRHRC studies,findings will be disseminated through atechnical report to ORHP, “Key Facts”sheets, presentations at state and nationalconferences, and through publication inthe medical and social sciences literature.

State Level Data ■ �

The North Carolina Rural Health GuidePolicy Analysis Center

Expected completion date: December 2006Principal Investigator: Katie Gaul, M.A., 919-966-6529 or [email protected]

Funder: The North Carolina Hospital Association (NCHA)

This project will provide assistance in theproduction of an on-line rural healthguide entitled “The North Carolina RuralHealth Guide” to be utilized by NorthCarolinians. The product of this project isan online resource system that can beused by rural hospitals and communities

who wish to better understand the healthcare needs and current capacity in theirlocal communities and facilities. Theonline product will be updated annuallywith current data.

VSTATE�LEVEL DATA


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Workforce ■ ��

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Chartbook of Family PracticeGraduate Medical Education Programs

in Rural AmericaWWAMI Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: L. Gary Hart, Ph.D., 206-685-0402 or [email protected]: Federal Office of Rural Health Policy, HRSA

percent of the training they supportedtook place in rural areas.

The chartbook contains graphs andtables, and presents national findings,geographic region, division findings, andstate findings. Findings are presented bytype of geography (isolated small rural,small rural, large rural, and urban), typeof rural training experience (model familypractice clinic, block rotations, ruraltraining tracks, and continuity clinics),and other residency characteristics. Someof the monograph diagrams show state-based rates of FTE training not previouslyreported, using population denominatorsso that comparisons of rural training perrural person can be compared across the50 states. A version of the monographwill be published on our Web site, and wewill disseminate hard copies of themonograph to residency directors,medical school deans, state healthworkforce committees, and federal healthworkforce policymakers.

Shortages of generalist physicians in U.S.rural areas have been an enduringproblem for many decades. The supply ofrural physicians is, in part, determined bythe number of family physicians whoreceive their residency training withinrural areas, along with the appropri-ateness of the content of their training forrural practices. However, little is knownabout the volume, location, and types ofrural training for family physicians. Thisproject will produce a chartbook thatmakes previously unreported informationabout family physician residencydirectors more fully available to medicaleducators and other policymakers.

Programs were asked to indicate theextent to which training rural physicianswas part of their core mission and tospecify where all residency trainingsponsored by their programs took place.Although over one-third of the urbanprograms listed rural training as animportant part of their mission, only 2.3

Development of a New Methodologyfor Dental Health Professional Shortage Area Designation

North Carolina Rural Health Research and Policy Analysis CenterExpected completion date: September 2005

Principal Investigator: Thomas Ricketts, Ph.D., 919-966-5541 or [email protected]: Health Resources and Services Administration

This project will develop a methodologyfor designating dental health professionalshortage areas within the United States,through the application of a conceptualmodel of dental access and use derived

from empirical studies. The model willguide the analysis of national dentalutilization data and their relationship tothe socio-demographic characteristics ofpotential dental care service areas in the


Is Rural Residency Training of Family Physiciansan Endangered Species? An Interim Follow-upto the 1999 National BBA StudyWWAMI Rural Health Research CenterExpected completion date: January 2005Principal Investigator: Roger Rosenblatt, M.D., M.P.H., 206-685-1361 or [email protected]: Federal Office of Rural Health Policy, HRSA

The shortage of physicians in ruralAmerica has persisted as physicianscontinue to settle preferentially inmetropolitan and suburban areas. One ofthe strategies to ameliorate this situationis the establishment of rural residencytraining. Since the completion of ourearlier survey of family medicineresidencies in the United States after thepassage of the Balanced Budget Act(BBA) of 1997, there has been aprecipitous decline in the proportion ofU.S. medical school graduates (USMGs)who have chosen to pursue residencytraining in family medicine. As a result,match rates of U.S. programs have beendeclining rapidly, and quite a fewprograms have closed. The impact ofthese trends on rural family medicinetraining capacity is unknown.

This study examined the proportionof rural-based family medicineresidencies that have ceased operationssince 2000, the residency-match experi-ences of the surviving programs, theproportion of USMGs and internationalmedical graduates, major issuesconfronting these rural residencies, andlikely impacts of these changes on thepreparation of future family physiciansfor rural America.

It was hypothesized that:■ Family medicine residencies in rural

areas have experienced a more rapiddecline in match rates than the entirepopulation of family medicalresidencies

■ Rural-based family medicineresidencies are beginning to close as aresult of falling match rates, and asubstantial number are planning toclose in subsequent years.

For this national study we used acombination of data collected in thelandmark baseline survey of 1999 withprimary data collected through a mailsurvey of the rural-based family medicineresidency-training programs. The surveyexamined the match rates of the rural-based programs over the last five years;which programs have downsized,consolidated, or actually closed since1999; what the plans are of theseprograms for the next two years, and towhat extent would continuing decline inmatch rates affect them; and theimplications for the rural areas that theseprograms serve. The final product will bea working paper plus a publicationsubmitted to a refereed journal. We willalso present the results of this study atlocal, regional, and national meetings.

United States. The analysis will create aset of factor weights that can be applied toareas to determine those that haveshortages of dental professionals.

Findings will be presented in adetailed methodology; a detailed analysisand summary of the effects of the

proposed methodology on designations;and data, summaries, and a detaileddescription of the application of theproposed methodology.


Long Term Trends in Characteristics of the Rural NurseWorkforce: A National Health Workforce Study

WWAMI Rural Health Research CenterExpected completion date: August 2005

Principal Investigator: Eric Larson, PhD., 206-685-0402 or [email protected]: Federal Office of Rural Health Policy, HRSA

to examine changes in the demographic,professional, and locational profiles of theRN population over two decades. Nurseshortages will be examined throughtrends in the ratio of the number of nursesworking in short-term general hospitalsto measures of hospital capacity andutilization. Trends in overall nursepopulation ratios will also be examined.

This national study will characterize theevolution of the rural/urban and regionalgeography of the current distribution andshortage of Registered Nurses (RNs), as itemerged between 1980 and 2000. Thestudy will use data from the NationalSample Survey of Registered Nurses(NSSRN) collected between 1980 and2000, supplemented with demographic,professional and health resourceinformation from the Area Resource File

National Changes in Physician SupplyWWAMI Rural Health Research CenterExpected completion date: January 2005

Principal Investigator: Eric Larson, Ph.D., 206-685-0401 or [email protected]: Federal Office of Rural Health Policy, HRSA

National rural health policy developmentdepends on an accurate and up-to-dateassessment of physician supply. Thisproject described the supply of generalistphysicians and osteopaths in rural areasof the U.S. The study results provide acurrent picture of rural physician supplyand its variation by state and by region.Data from the American MedicalAssociation Physician Masterfile and theArea Resource File were used to

determine the total supply of practicingphysicians in metropolitan andnonmetropolitan counties in 1998.Assessment was made of the supply ofphysicians in the smallest and mostisolated areas of the country, and ruralphysician supply was analyzed on a state-by-state and regional basis.


Rural Health Center Expansion and Recruitment SurveyWWAMI Rural Health Research Center andSouth Carolina Rural Health Research CenterExpected completion date: May 2005Principal Investigators: Roger Rosenblatt, M.D., M.P.H., 206-685-0402 [email protected] or Janice C. Probst, Ph.D., 803-777-7426 or [email protected]: Federal Office of Rural Health Policy, HRSA

This collaborative project will examineand describe the current staffing needs ofrural health centers (RHCs), ascertain thestaffing, recruitment, and retention issuesthat rural health center CEOs regard asmost critical; distinguish how issues differbetween CEOs contemplating develop-ment of expansion sites versus those whoare not; and describe how these findingscorrelate with the literature and currentnational supply projections for thecategories of health professions neededby the RHCs.

RHCs face major barriers in recruitingand retaining health professionals, yetthere are no projections of key healthprofessions’ staffing needs for RHCs andproposed new RHCs. While RHCs reporton staffing via the Uniform Data System,this does not include critical information

on vacancies, recruitment and retention,and other important issues. TheNational Association of CommunityHealth Centers administered a mailquestionnaire to the CEOs of all RHCsthat examines current vacancies,projected staffing needs, recruitmentand retention issues, center siteexpansion plans, and CEO perception ofpolicies that would facilitate recruitmentand retention. The WWAMI RuralHealth Research Center is involved inthe analysis of these data, and a jointreport with the South Carolina RuralHealth Research Center will beproduced. This project is a collaborationbetween the federal Office of RuralHealth Policy, the Bureau of PrimaryHealth Care, and the Bureau of HealthProfessions.

Rural-Urban Physician Payment DifferencesAcross the Nation: Methodological ChangesRUPRI Center for Rural Health Policy AnalysisExpected completion date: April 2005Principal Investigator: A. Clinton MacKinney, M.D., M.S., 320-363-8150 or [email protected]: Federal Office of Rural Health Policy, HRSA

This project will simulate the effects ofchanges to the methodologies used tocalculate the three geographic priceindices (GPCIs) used to adjust physicianpayment across the 89 Medicare paymentareas in the U.S. and territories. Healthservices researchers are concerned aboutthe methodology used to determine theGPCIs. In particular, concerns have beenraised about the timeliness of updates tothe indices, the appropriateness of the

data used to compute the indices, and themethodology in general.

This project is designed to provide adispassionate explanation of paymentdifferences as a function of payment area,with illustration of specific differencesthat result from separate GPCIs, andanalyze changes to the payment formulato determine potential impact on paymentacross areas and revenues for ruralphysician practices.


physicians a significant amount (5%or more) with changes in Medicarepayment that closed the gap betweenthe lowest and highest GPCIs (allthree components aggregated).

Two policy papers and three policy briefswill be produced.

The following hypotheses will be tested:■ Payment to rural primary care

physicians would increase if the workGPCI were calibrated using morerecent data and a different mix ofoccupational categories

■ Payment to rural primary carephysicians would increase if thepractice expense GPCI was calibratedusing different input variables

■ Overall practice income wouldincrease for rural primary care

Southeast Regional Center for Health Workforce Studieshttp://www.healthworkforce.unc.eduExpected completion date: September 2006Director and Principal Investigator: Thomas Ricketts, Ph.D., 919-966-5541 or [email protected]: Bureau of Health Professions, HRSA

The Southeast Regional Center for HealthWorkforce Studies is supported by acooperative agreement with the NationalCenter for Health Workforce Analysis inthe Bureau of Health Professions, HRSA,and is one of six federally designatedregional workforce analysis centers. TheCenter conducts research and analysiswith the goal of improving access to anappropriate and effective healthworkforce in the Southeast and NorthCarolina. The Center draws on theresources of the Chapel Hill Campus withits five health professions schools:medicine, pharmacy, dentistry, publichealth, and nursing, as well as the 16-campus University of North Carolinasystem to respond to the information andanalysis needs of health workforce policymakers in the state, the region, and thenation. The Center also collects andmaintains data describing the need for

and supply of health professionals, andmakes these data available for researchand policy analysis purposes.

The Center’s current projects are:■ Developing Productivity Measures for

Workforce Programs■ Do NHSC Dentist Alumni Remain in

the Oral Health Safety Net■ Population Characteristics of Nursing

Employment Patterns■ Service-Requiring Scholarships and

Loan Repayment for Nurses in theSoutheast

■ Technical Assistance Network toImprove Health Workforce DataCollection and Reporting in SoutheastStates

■ Technical Assistance to the Region 4States.

http://www.healthworkforce.unc.edu


The State of Rural Health Provider Organizations and HealthProfessional ShortagesSouthwest Rural Health Research CenterExpected completion date: December 2004Principal Investigator: James Alexander, Ph.D., 979-458-1592 or [email protected]: Federal Office of Rural Health Policy, HRSA

This study addresses the convergence ofhealth profession shortages and financiallimitations among rural hospitals andrural home health providers. Althoughsome attention has been given toshortages of nurses and/or allied healthprofessionals or to finances of these twoproviders, there is a gap in knowledge ofthe linkages between financial andshortage conditions. There are gaps, too,relating to combinations of theseconditions to degree of rurality, otherlocal conditions, and to strategies adoptedto address these two conditions. Inaddition to secondary data collection, asurvey of rural hospitals and home careproviders from the four regions of theUnited States was conducted to determinethe number of health care professionals

employed and the number of unfilledpositions. The survey is particularlyinterested in shortages in nursing and abroad range of other allied healthprovider professions. In addition, theproject identified successful strategies orbest practices implemented in rural areasto address the rural health care providershortage in an environment of decreasedrevenues. These models will be sharedthrough the Center’s website as well asthrough other dissemination efforts.

In addition to a final report, theresearch team plans to present findings atthe National Rural Health AssociationMeeting and other professional meetingsas well as submit articles to professionaljournals.

Stay or Leave:Evidence from a Cohort of Young Rural PhysiciansWalsh Center for Rural Health AnalysisExpected completion date: December 2004Principal Investigator: Curt D. Mueller, Ph.D., 301-951-5070 or [email protected]: Federal Office of Rural Health Policy, HRSA

The purpose of this project is to improveour understanding of the dynamics ofphysician practice location decision-making. The inability of rural areas toattract and retain physicians has been ofconcern to health services researchers andpolicy makers for many years. Workforcesupply constraints may adversely affectaccess to care and outcomes in theseareas. Much of the evidence on howphysicians make practice locationdecisions is static which tends tooverestimate behavior of those who serve

rural areas for longer periods of time. Abetter understanding of the dynamics ofbehavior is needed, e.g., studies ofobserved changes in practice locationsover time by a cohort of providers.

This project tracked practice locationsof a cohort of physicians usinginformation on physicians who wereidentified during the early stages of theirmedical careers as part of the NationalSurvey of Rural Physicians (NSRP),conducted in 1993-1994 with fundingfrom the Robert Wood Johnson


Foundation. We supplemented these datawith data obtained from the AmericanMedical Association when the NSRPsampling frames were constructed, withinformation on the current practice locationsof physicians in the cohort, and with datafrom a follow-up survey. We examinedchanges in practice locations for allphysicians in the sampling frame. For the

subset of sampled physicians who respondedto the NSRP, we identified factors correlatedwith the decision to maintain a rural practice.Contingency tables were used to test a varietyof hypotheses concerning factors affecting thephysician’s decision to continue practice in arural community, along with statisticalanalyses to examine relationships betweenthese factors.

University of Washington Center for Health Workforce Studieshttp://www.fammed.washington.edu/CHWS/

Director and Principal Investigator: L Gary Hart, Ph.D., 206-685-0401 or [email protected]: Bureau of Health Professions, HRSA

The University of Washington Center forHealth Workforce Studies (CHWS) wasestablished at the University of Washingtonin 1998 with funding from the Bureau ofHealth Profession's National Center forHealth Workforce Analysis. It is based in theResearch Section of the Department of FamilyMedicine, University of Washington School ofMedicine, and is directed by L. Gary Hartwho also directs the WWAMI Rural HealthResearch Center.

The Workforce Center’s major goalsare to:■ Conduct relevant health workforce

research and policy analysis incollaboration with federal and stateagencies

■ Provide consultation to local, state,regional, and national policymakers onhealth workforce issues

■ Contribute to the understanding of healthworkforce issues and findings

■ Disseminates study results to a wideaudience for application by policymakers.

The Center’s current projects are:■ An Analysis of Factors that Affect the

Acceptance of American Indians/AlaskaNatives into Medical School TrainingPrograms

■ Dental Hygienists in Washington: 2004Survey of Demographics, Education andWork Characteristics

■ Effects of the Increasing Number ofInternational Medical Graduates inPrimary Care Residencies

■ International Medical Graduates andTheir Role in U.S. Physician Supply

■ International Nurse Graduates in theU.S. - Geographic Trends

■ Longitudinal Analysis of InternationalMedical Graduates

■ Student Debt and the Decline in PrimaryCare: Can Medical School Graduates StillAfford to Become Primary Care Doctors?

■ Survey of Registered Nurses Who HaveNot Renewed Their Washington Licenses

■ Washington’s Obstetrics Provider Survey:Practice Characteristics and Effects ofChanges in Liability Insurance

■ Washington State Hospitals: Results of2003-4 Workforce Survey.

http://www.fammed.washington.edu/CHWS/


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Which Training Programs Produce Rural Physicians?A National Health Workforce StudyWWAMI Rural Health Research CenterExpected completion date: August 2005Principal Investigator: L. Gary Hart, Ph.D., 206-685-0402 or [email protected]: Federal Office of Rural Health Policy, HRSA

This national study is usingcomprehensive, longitudinal data onmedical school specialty and practicelocation choice to determine the extent towhich the nation’s medical schools andresidency programs vary in theirproduction of rural physicians. Thisinformation will be used to identify themedical school and residency trainingcharacteristics that result in the highestyield of rural physicians. This projectupdates and builds on previous WWAMIRHRC studies by including elements notpreviously available: the type andlocation of residency training, a moresophisticated method for defining

rurality, and a new approach todetermining physician supply at the levelof the Primary Care Service Area. Theproject will show variation by medicalschools in the number and proportion oftheir graduates who practice in ruralareas, identify how this production variesby residency type, compare theproduction of rural physicians betweenosteopathic and allopathic schools,examine the comparative production ofmale and female physicians within andacross medical schools, and comparethese findings with those from our 1992project.

Part 2: Center Descriptions/Publications ■ ��

Part �: Research Center Descriptions/Publications

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Analytic Centers:NORC Walsh Center for Rural Health AnalysisNorth Carolina Rural Health Research and Policy Analysis CenterRUPRI Center for Rural Health Policy Analysis

General Centers:Maine Rural Health Research CenterSouth Carolina Rural Health Research CenterUpper Midwest Rural Health Research CenterWICHE Rural Mental Health Research CenterWWAMI Rural Health Research Center

Center Descriptions and Publications:Maine Rural Health Research Center ��

NORC Walsh Center for Rural Health Analysis ��

North Carolina Rural Health Research andPolicy Analysis Center ��

RUPRI Center for Rural Health Policy Analysis ��

South Carolina Rural Health Research Center ��

Southwest Rural Health Research Center* ��

Upper Midwest Rural Health Research Center ��

WICHE Rural Mental Health Research Center ��

WWAMI Rural Health Research Center ��

* Funded by the Federal Office of Rural Health Policy FYs ��

Part 2:Rural Health Research CentersDescriptions and Publications


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Maine Rural Health Research Center ■ ��

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terInstitute for Health Policy, Muskie School of Public Service

University of Southern MainePO Box 9300, Portland, Maine 04104-9300207-780-4430 • Fax [email protected]; [email protected]://muskie.usm.maine.edu/ihp/ruralhealth

Established in 1992, the Maine Rural Health Research Center draws on themultidisciplinary faculty, research resources and capacity of the Institute forHealth Policy within the Edmund S. Muskie School of Public Service, Universityof Southern Maine. Rural health is one of the primary areas of research andpolicy analysis within the Institute for Health Policy, and builds on theInstitute’s strong record of research, policy analysis, and policy development inthe following focus areas:

■ Chronic Illness, Disability, and Aging

■ Health Care Access and Finance

■ Mental Health

■ Public Health

■ Health Care Quality Management and Improvement

■ Children’s Health and Welfare

The mission of the Maine Rural Health Research Center is to inform health carepolicymaking and the delivery of rural health services through high quality,policy relevant research, policy analysis and technical assistance on rural healthissues of regional and national significance. The Center is committed toenhancing policymaking and improving the delivery and financing of ruralhealth services by effectively linking its research to the policy developmentprocess through appropriate dissemination strategies. The Center’s portfolio ofrural health services research addresses critical, policy relevant issues in healthcare access and financing, rural hospitals, primary care and behavioral health.The Center’s core funding from the federal Office of Rural Health Policy istargeted to behavioral health.

Maine Rural Health Research CenterDirector: David Hartley, Ph.D.Deputy Director: Andrew F. Coburn, Ph.D.

http://muskie.usm.maine.edu/ihp/ruralhealth


Current PublicationsFor publications prior to 2004, please visit the Center’s website athttp://muskie.usm.maine.edu/ihp/ruralhealth/

Working Papers

31. Hartley D, Hart V, Hanrahan N & Loux S. (2004). Are advanced practice psychiatric nurses asolution to rural mental health workforce shortages?

Other Publications

Forthcoming

Coburn AF, McBride T, Ziller E & Andrews C. (forthcoming). Rural and urban patterns ofindividual health insurance coverage. Medical Care Research and Review.

Loux SL, Payne SMC & Knott A. (forthcoming). Comparing patient safety in rural hospitals bybed count. In Advances in Patient Safety: From research to implementation. Rockville, MD:Agency for Healthcare Research and Quality.

2004

Coburn AF, Wakefield M, Casey M, Moscovice I, Payne SMC & Loux S. (2004). Assuring ruralhospital patient safety: What should be the priorities? Journal of Rural Health, 20(4), 314-326.Special issue on Pursuing Healthcare Quality and Safety in the Rural Environment.

Hartley D. (2004). Rural health disparities, population health, and rural culture. American Journalof Public Health, 94(10), 1675-1678.

Pearson KB. (Ed.). (2004). Rural health research in progress in the Rural Health Research CentersProgram (8th ed.). Portland, ME: University of Southern Maine, Edmund S. Muskie Schoolof Public Service, Institute for Health Policy, Maine Rural Health Research Center.

Ziller EC, Coburn AF, McBride TD & Andrews C. (2004). Patterns of individual healthinsurance coverage, 1996-2000. Health Affairs, 23(6), 210-221.

http://www.muskie.usm.maine.edu/Publications/rural/wp31.pdf

http://muskie.usm.maine.edu/ihp/ruralhealth/

http://www.muskie.usm.maine.edu/Publications/rural/wp31.pdf

NORC Walsh Center for Rural Health Analysis ■ ��

NORC Walsh Center forRural Health AnalysisDirector: Curt D. Mueller, Ph.D.Associate Director: Julie A. Schoenman, Ph.D.

National Opinion Research Center7500 Old Georgetown Road, Suite 620, Bethesda, Maryland 20814301-951-5070 / 202-887-2356 (Curt)[email protected]; [email protected]://www.norc.org

The NORC Walsh Center for Rural Health Analysis was established in 1996 tostudy policy issues affecting health care in rural America. The Center’s currentfocus is on the impact of Medicare policies on rural communities. Centerproducts have addressed implications of Medicare payment policies, access tocare, home health issues, emergency medical services issues, and location andpractice decisions of rural physicians and other providers. Center researchershave conducted simulations on changes in provider payment methodologiesand conduct research and analysis using data collected by the Center and datafrom other sources, including Medicare claims, the Medicare Cost Reports, theNational Health Interview Survey (NHIS), the National Medical ExpenditureSurvey (NMES), and the Medicare Current Beneficiary Survey (MCBS). NORCWalsh Center researchers have presented study findings to Congressionalcommissions and contributed to Department of Health and Human Servicesreports to Congress.

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Current Publications

For publications prior to 2004, please contact the Walsh Center at 301-951-5070.

Policy Papers

Mueller CD. (2004). Trends in hospital outpatient revenue: Baselines for study of impacts of theoutpatient payment system.

Mueller CD, Mueller KJ & Sutton J. (2004). A rural perspective regarding regulations implementingTitles I and II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003(MMA). Joint Publication of the NORC Walsh Center and RUPRI Center for Rural HealthPolicy.

Schoenman JA & Mueller CD. (2004). Rural implications of Medicare’s post-acute care transferpayment policy.

Schur CL. (2004). Understanding the role of the rural hospital emergency department in responding tobioterrorist attacks and other emergencies: A review of the literature and guide to the issues.

Sutton J. (2004). Access to primary care and quality of care in rural America.

Policy Analysis Briefs

No.1. Franco S. (2004). Medicare home health care in rural America.

No.2. Blanchfield B, Franco S, Stensland J & Sutton J. (2004). Financially distressed rural hospitalsin four states.

No.3. Sutton J & Dunn T. (2004). Rural hospitals’ strategies for achieving compliance with HIPAAprivacy requirements.

No.4. Schur C, Berk M & Mueller C. (2004). Perspectives of rural hospitals on bioterrorismpreparedness planning.

No.5. Schoenman JA. (2004). Exploring the impact of Medicare’s post-acute care transfer policy on ruralhospitals.

Other Publications

Mueller CD & Schur CL. (2004). Insurance coverage of prescription drugs and the rural elderly.The Journal of Rural Health, 20(1), 17-25.

North Carolina Rural Health Research and Policy Analysis Center ■ ��

North Carolina Rural Health Research andPolicy Analysis CenterDirector: Rebecca T. Slifkin, Ph.D.

Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill725 Airport Road CB 7590, Chapel Hill, NC 27599-7590919-966-5541 • Fax: [email protected]://www.shepscenter.unc.edu

The North Carolina Rural Health Research and Policy Analysis Center isone of three federally designated Rural Health Policy Analysis Centersfunded by the Federal Office of Rural Health Policy. The Center is built onthe 30-year history of rural health services research at the University ofNorth Carolina’s Cecil G. Sheps Center for Health Services Research, and isable, through that relationship, to draw on the experience of a wide varietyof scholars, researchers, analysts, managers and health service providers.The Center also has an ongoing partnership with the Foundation forAlternative Health Programs of the Office of Rural Health and ResourceDevelopment in the North Carolina Department of Human Resources.

The Center seeks to address problems in the rural health arena throughpolicy-relevant analyses, the geographic and graphical presentation of data,and the dissemination of information to organizations and individuals inthe health care field who can use this material for policy or administrativepurposes. The Center’s research involves primary data collection, analysisof large secondary data sets, and in-depth policy analysis. The Center bringstogether a diverse, multidisciplinary team including clinicians in medicine,nursing, pharmacy, allied health, mental health and other professions anddisciplines along with experts in biostatistics, geography, epidemiology,sociology, anthropology and political science to address complex socialissues affecting rural populations.

The Center’s present agenda focuses on federal insurance programs(Medicare and Medicaid) and their effect on rural populations. Currentprojects include the examinations of premium assistance programs, andtrends in swing bed and skilled nursing facility use in rural hospitals (1996-2003), and a description of geographic access to physicians in rural Americausing statistical applications in GIS.

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Current PublicationsFor publications prior to 2004, please visit the Center’s website at:http://www.schsr.unc.edu/research_programs/rural_program/papers.html

Working Papers, Reports, and Findings Briefs

WP80. Greene S, Holmes G, Slifkin R, Freeman V & Howard A. (2004). Caesarean section patternsin rural hospitals.http://www.shepscenter.unc.edu/research_programs/rural_program/WP80.pdf

WP79. Mueller K, Slifkin R, Shambaugh-Miller M & Randolph R. (2004). Definition of rural in thecontext of MMA access standards for prescription drug plans. A joint publication of the RUPRICenter for Health Policy Analysis and the North Carolina Rural Health Research and PolicyAnalysis Center.http://www.shepscenter.unc.edu/research_programs/rural_program/wp79.pdf

FB78. Dalton K & Slifkin RT. (2004). Rural-urban issues in the wage index adjustment for prospectivepayment in skilled nursing facilities.http://www.shepscenter.unc.edu/research_programs/rural_program/FB78.pdf

Dalton K & Slifkin, R. (2004). Adjusting for occupation mix differences in the Medicarehospital wage index.http://www.shepscenter.unc.edu/research_programs/rural_program/OccMix.pdf

Dalton K & Slifkin RT. (2004). Core based statistical areas and the Medicare wage index.http://www.shepscenter.unc.edu/research_programs/rural_program/cbsa.pdf

Other Publications

Forthcoming

Dalton K, Slifkin R, Poley S & Fruhbeis M. (in press). A profile of facilities choosing toparticipate in the Rural Hospital Flexibility Program. Health Care Financing Review.

Fraher EP, Slifkin RT, Smith L, Randolph R, Rudolf M & Holmes GM. (forthcoming).Implications of the Medicare Prescription Drug, Improvement, and Modernization Act of2003 for the financial viability of rural pharmacies. Journal of Rural Health.

Holmes GM. (in press). Does the National Health Service Corps improve physician supply inunderserved locations? Eastern Economic Journal.

Holmes GM. (in press). Increasing physician supply in medically underserved areas. LaborEconomics.

http://www.schsr.unc.edu/research_programs/rural_program/papers.html

http://www.shepscenter.unc.edu/research_programs/rural_program/WP80.pdf

http://www.shepscenter.unc.edu/research_programs/rural_program/wp79.pdf

http://www.shepscenter.unc.edu/research_programs/rural_program/FB78.pdf

http://www.shepscenter.unc.edu/research_programs/rural_program/OccMix.pdf

http://www.shepscenter.unc.edu/research_programs/rural_program/cbsa.pdf

North Carolina Rural Health Research and Policy Analysis Center ■ ��

Mayer ML, Slifkin RT & Skinner AC. (forthcoming). The effect of rural residence and othersocial vulnerabilities on subjective measures of unmet need. Medical Care Research andReview.

Skinner AC, Slifkin RT & Mayer M. (forthcoming). The effect of rural residence on dentalunmet need for children with special health care needs. Journal of Rural Health.

2005

Ricketts TC. (2005). Workforce issues in rural areas: A focus on policy equity. American Journal ofPublic Health, 95(1), 42-48.

2004

Pathman DE, Konrad TR, Dann R & Koch G. (2004). Retention of primary care physicians inrural health professional shortage areas. American Journal of Public Health, 94(10), 1723-1729.

Pink GH, Slifkin RT, Coburn AF & Gale J. (2004). Comparative performance data for criticalaccess hospitals. Journal of Rural Health, 20(4), 374-382.

Ricketts TC. (2004). Arguing for rural health: Toward a progressive rhetoric for America. Journalof Rural Health, 20(1), 43-51.

Slifkin R, Randolph RT & Ricketts TC. (2004). The changing metropolitan designation processand rural America. Journal of Rural Health, 20(1), 1-6.


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RUPRI Center for Rural Health Policy Analysis ■ ��

Rural Policy Research InstituteCenter for Rural Health Policy AnalysisDirector: Keith J. Mueller, Ph.D.

University of Nebraska Medical Center984350 Nebraska Medical CenterOmaha, NE 68198-4350402-559-5260 • Fax: [email protected]://www.rupri.org/healthpolicy

The mission of the Rural Policy Research Institute (RUPRI) Center forRural Health Policy Analysis is to provide timely analysis to federaland state health policymakers based on the best available research.

The research of the RUPRI Center focuses on rural health carefinancing/system reform, rural systems building, and meeting thehealth care needs of special rural populations. Specific objectivesinclude:

■ Conducting original research and independent policy analysis thatprovides policymakers and others with a more completeunderstanding of the implications of health policy initiatives

■ Disseminating policy analysis that assures policymakers willconsider the needs of rural health care delivery systems in thedesign and implementation of health policy.

The RUPRI Center for Rural Health Policy Analysis is based at theUniversity of Nebraska Medical Center, in the Department ofPreventive and Societal Medicine, Section on Health Services Researchand Rural Health Policy.

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Current PublicationsFor publications prior to 2004, please visit the RUPRI website at http://www.rupri.org/

Reports and Policy Papers

P2004-7. Mueller KJ, Slifkin RT, Shambaugh-Miller MD & Randolph RK. (September 2004).Definition of rural in the context of MMA access standards for prescription drug plans. A jointpublication of the RUPRI Center for Health Policy Analysis and the North Carolina RuralHealth Research and Policy Analysis Center.http://www.rupri.org/ruralPolicy/publications/p2004-7.pdf

P2004-6. Mueller C, Mueller K & Sutton J. (August 2004). A rural perspective regarding regulationsimplementing Titles 1 and II of the Medicare Prescription Drug, Improvement, and Modernization Actof 2003. A joint publication of the NORC Walsh Center for Rural Health Analysis and theRUPRI Center for Health Policy Analysis.http://www.rupri.org/ruralPolicy/publications/P2004-6.pdf

P2004-3. Mueller KJ, Shay B, Hart JP, Harrop D & Rasmussen, D. (April 2004). Informationtechnology and rural health networks: An overview of network practices. http://www.rupri.org/ruralHealth/publications/p2004-3.pdf

P2004-1. Mueller KJ. (January 2004). The Medicare Prescription Drug, Improvement, andModernization Act of 2003 (P.L. 108-173). A summary of provisions important to rural health caredelivery.http://www.rupri.org/ruralHealth/publications/MedicareLegislationPolicyPaperupdated.pdf

Policy Briefs

PB2004-5. Mueller K, MacKinney AC, McBride TD, Mesa JL & Xu L. (August 2004). Ruralphysicians’ acceptance of new Medicare patients.http://www.rupri.org/ruralPolicy/publications/PB2004-5.pdf

PB2004-4. Chen L, Stoner J, Makhanu C, Minikus K & Mueller KJ. (May 2004). An analysis of theagreement between financial data from the Medicare Cost Report and the audited hospital financialstatement.http://www.rupri.org/ruralPolicy/publications/PB2004-4.pdf

Other Publications

Jones KJ, Cochran G, Hicks RW & Mueller KJ. (2004). Translating research into practice:Voluntary reporting of medication errors in critical access hospitals. Journal of Rural Health,20(4), 335-343.

http://www.rupri.org/

http://www.rupri.org/ruralPolicy/publications/p2004-7.pdf

http://www.rupri.org/ruralPolicy/publications/P2004-6.pdf

http://www.rupri.org/

http://www.rupri.org/ruralHealth/publications/MedicareLegislationPolicyPaperupdated.pdf

http://www.rupri.org/ruralPolicy/publications/PB2004-5.pdf

http://www.rupri.org/ruralPolicy/publications/PB2004-4.pdf

South Carolina Rural Health Research Center ■ ��

South Carolina Rural Health Research CenterDirector: Janice C. Probst, Ph.D.Deputy Director: Charity Moore, Ph.D.

Arnold School of Public HealthUniversity of South Carolina220 Stoneridge Drive, Suite 204Columbia, SC 29210803-251-6317 • Fax: [email protected]; [email protected]://rhr.sph.sc.edu

The mission of the South Carolina Rural Health Research Center is to shedlight on persistent inequities in health status among the population of therural US with an emphasis on factors related to socioeconomic status, raceand ethnicity, and access to healthcare services. Through the attainment ofthis mission, the Center also hopes to achieve the following:

■ Develop and conduct the research necessary to provide a clear pictureof health status, health care needs, health service use, and healthoutcomes among rural, minority groups

■ Investigate the effectiveness of policies aimed at improving health andreducing the barriers to health care for rural poor and minorityindividuals

■ Promote the development of minority researchers and clinical providersinterested in addressing the problems of rural poor and minoritypopulations

■ Stimulate health services research, demonstration, clinical trial, andservices capacity in the rural minority communities

■ Provide expert advice to national, state, and local governments as wellas to rural and minority constituency groups to empower policydevelopment and advocacy

■ Develop a repository of knowledge and information on poor andminority health issues.

The Center is based in the Department of Health Services Management andPolicy, Arnold School of Public Health, University of South Carolina. Ourresearch partners include: Office of Research, South Carolina Budget andControl Board, Department of Family and Preventive Medicine, Universityof South Carolina School of Medicine, College of Nursing and Departmentof Family Medicine, Medical University of South Carolina.

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Current PublicationsFor publications prior to 2004, please visit the Center’s website at http://rhr.sph.sc.edu

Working Papers and Reports

Forthcoming

Laditka SB, Laditka JN, Probst JC, Bennett KJ, Johnson A & Mink M. (forthcoming). Impact ofMedicaid managed care, race/ethnicity, and rural/urban residence on access to prenatal care: A multi-level multi-state analysis.

Mainous AG, Koopman R & Geesey ME. (forthcoming). Diabetes and hypertension in ruralHispanics.

Mink M, Moore CG, Johnson A & Probst JC. (forthcoming). Violence and rural teens: A nationalstudy of exposure to violence, mental health services, and violence prevention programs.

Moore CG, Mink M, Probst JC, Johnson A & Hughley S. (forthcoming). Mental health risk factors,unmet needs and provider availability for rural children.

Powell MP, Glover SH, Probst JC & Laditka SB. (forthcoming). Assessment of barriers to thedelivery of Medicare reimbursed diabetes self-management education in rural areas.

2004

Patterson PD, Probst JC & Moore CG. (2004, August) Investigating rural Emergency MedicalService (EMS) infrastructure: A developmental methodology for measuring the availability of EMSresources.

Erkel EA, Moore CG & Michel Y. (2004, February). Resource mothers: The effect of a rural lay homevisitation program on maternal-infant preventive services and health outcomes.

Other Publications

Forthcoming

Laditka SB, Laditka JN, Bennett KJ & Probst JC. (forthcoming). Rural/urban differences inoutcomes associated with prenatal care access among Medicaid-insured mothers andinfants. Journal of Rural Health.

Mainous AG, King DE, Garr DR & Pearson WS. (forthcoming). The influence of race and ruralresidence on disparities in diagnoses and control of diabetes and hypertension. AmericanJournal of Public Health.


South Carolina Rural Health Research Center ■ ��

Patterson PD, Probst JC, Leith K, Corwin S & Powell MP. (forthcoming). Recruitment andretention of EMTs: A qualitative study. Journal of Allied Health.

Probst JC, Moore CG & Baxley EG. (forthcoming). Update: Health insurance andutilization of care among rural adolescents. Journal of Rural Health.

2004

Glover S, Moore CG, Samuels ME & Probst JC. (2004). Disparities in access to care amongrural working-age adults. Journal of Rural Health, 20(3), 193-205.

Patterson DP, Moore CG, Shinogle JA & Probst JC. (2004). Obesity and physical inactivityspread to rural America. Journal of Rural Health, 20(2), 151-9

Moore CG, Glover SH & Samuels ME. (2004). Person and place: The compounding effectsof race/ethnicity and rurality on health. American Journal of Public Health, 94(10), 1695-1703.


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Southwest Rural Health Research Center ■ ��

Southwest Rural Health Research CenterDirector: Catherine Hawes, Ph.D.Associate Director: Larry Gamm, Ph.D.

School of Rural Public Health, 1266 TAMUTexas A&M University System Health Science CenterCollege Station, Texas 77843-1266(979) 458-0653 or (979) 458-0081 (Hawes) • Fax: (979) [email protected], [email protected]://www.srph.tamhsc.edu/srhrc

The Southwest Rural Health Research Center (SRHRC) at the TexasA&M University System Health Science Center School of Rural PublicHealth is one of six rural health research centers funded by the federalOffice of Rural Health Policy. The SRHRC is an integral part of the onlyschool of public health with a specific focus on rural issues, the School ofRural Public Health in the Texas A&M University System Health ScienceCenter. The SRHRC was founded in 2000 and serves as a focal point foruniting other parts of the Texas A&M System to conduct anddisseminate policy-relevant research on critical rural health issues. TexasA&M, however, has a long history of conducting research, education,and service in rural areas. Thus, the SRHRC draws its seniorinvestigators from across the University and the Health Science Center,including the School of Rural Public Health, the College of Medicine, theCenter for Health Services Research, the Center for Housing and UrbanDevelopment, the Department of Rural Sociology and the Public PolicyResearch Institute.

The Center and its investigators conduct policy-relevant research ina number of areas. However, SRHRC has selected three main areas offocus as part of its work for the federal Office of Rural Health Policy.

■ Meeting the needs of special rural populations, particularly thosewith chronic diseases and disabilities

■ Understanding and addressing the special health needs of minoritypopulations and eliminating or reducing health disparities

■ Maintaining and building the capacity of rural health systems.

In addition, the SRHRC has several long-term objectives that are anoutgrowth of both the mission of the Texas A&M School of Rural PublicHealth and the interests and long-term commitments of core andaffiliated faculty of the SRHRC. In particular, the SRHRC collaborateswith other Texas A&M entities on policy analyses and programevaluations for state and federal agencies on projects and studies thathave a specific focus on issues related to rural health or health care forvulnerable or disadvantaged populations. Finally, SRHRC is part of along-standing tradition at Texas A&M in implementing and evaluatingcommunity health interventions in rural and border areas.

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Current PublicationsFor publications prior to 2004, please visit the Center’s website at:http://www.srph.tamhsc.edu/centers/srhrc

Working Papers, Reports, and Policy Briefs

Alexander J & Gamm L. (forthcoming). The state of health provider organizations and healthprofessional shortages.

Bolin JN. (2004, February). Newsletter: Chronic disease management in rural areas: A research update.

Bolin JN & Gamm L. (2004). Chronic disease management in rural areas: Examination of Medicare andMedicaid managed care programs.

Gamm L & Castillo G. (2004). Educational and community-based programs in rural areas: Aliterature review. In L. Gamm & L. Hutchison (Eds.). Rural Healthy People 2010: A companiondocument to Healthy People 2010. Volume 3. Accessible at http://www.srph.tamhsc.edu/centers/rhp2010

Gamm L & Hutchison L. (2004). Mental health and substance abuse services: Prospects forrural communities. (White Paper Report to the Institute of Medicine’s Workshop on theFuture of Rural Health, Washington, DC, March 2004.)

Hutchison L & Hawes C. (2004). Access to long term care in rural America. In G L. Gamm & L.Hutchison (Eds.). Rural Healthy People 2010: A companion document to Healthy People 2010.Volume 3. Accessible at http://www.srph.tamhsc.edu/centers/rhp2010

May M & Contreras R. (2004). Mujer y corazon: Community health workers and their organizations inColonias on the US-Mexico Border. An exploratory study.

May M, Contreras R & Kash B. (2004). The community health worker certification (CHW) process: Anational survey and a state of Texas case study with the focus on implications for practice and policy.

Phillips CD, Hawes C, Sherman M & Leyk Williams M. (2004). Nursing home residents in ruraland urban areas, 2001 (A chartbook).

Quiram B, Meit M, Carpender K. et al. (2004). Public health infrastruture in rural areas: Aliterature review. In L. Gamm & L. Hutchison (Eds.). Rural Healthy People 2010: A companiondocument to Healthy People 2010. Volume 3. Accessible at http://www.srph.tamhsc.edu/rhp2010

Zuniga MA. (forthcoming). Medication use among residents of rural assisted living facilities.

http://www.srph.tamhsc.edu/centers/srhrc

http://www.srph.tamhsc.edu/

http://www.srph.tamhsc.edu/centers/rhp2010

http://www.srph.tamhsc.edu/

Southwest Rural Health Research Center ■ ��

Policy Briefs

Bolin JN. (2004, May). Policy Brief: Chronic disease management in rural areas.

Hawes C. (2004, Spring). Policy Brief: Assisted living: Is it an option for rural areas?

Hawes C. (2004, Spring). Policy Brief: Expanding residential care and assisted living in rural areas.

Hawes C. (2004, October). Policy Brief: Mujer y corazon. Community health workers and theirorganizations in Colonias on the US-Mexico border.

Other Publications

Forthcoming

Bolin JN, Gaubeca V & Zazworsky D. (Eds.). (forthcoming). Handbook of diabetes and diseasemanagement. Kluewer Press.

Bolin JN, Phillips CD & Hawes C. (forthcoming). Nursing home admissions in rural andnon-rural areas: Resident characteristics and care needs in a national admission sample.Gerontologist.

Bolin JN, Phillips CD & Hawes C. (forthcoming). Urban/rural differences in end-of-lifepatient in nursing facilities: Their characteristics and treatment differences. Journal ofRural Health.

Hawes C, Phillips CD, Holan S et al. (forthcoming). Assisting living in rural America:Results of a national study. Journal of Rural Health.

Phillips CD, Holan S, Sherman M, Hawes C & Spector W. (in press). Medicare expendituresby individuals residing in assisted living facilities. Health Services Research.

Phillips CD & Hawes C. (forthcoming). Care provision in housing with supportive services:The importance of care type, individual characteristics and care site. Journal of AppliedGerontology.

2004

Buchanan RJ, Bolin JN, Wang S, Zhu L, & Kim MS. (2004). Urban/rural differences indecision making and the use of advance directives among nursing home residents atadmission. Journal of Rural Health, 20(2), 131-135.

Gamm L & Hutchison L. (2004). Rural Healthy People 2010—Evolving interactive practice.American Journal of Public Health, 94(10), 1711.


Phillips CD, Holan S, Leyk Williams M, Sherman M & Hawes C. (2004). Rurality and nursinghome quality: Results from a national sample of admissions. American Journal of PublicHealth, 94(10), 1717-1722.

Phillips CD & McLeroy KL. (2004). Health in rural America: Remembering the importance ofplace. American Journal of Public Health, 94(10), 1661-1663.

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Upper Midwest Rural Health Research Center ■ ��

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Upper Midwest Rural Health Research CenterDirector: Ira Moscovice, Ph.D.Deputy Director: Mary Wakefield, Ph.D., R.N.

University of Minnesota Rural Health Research Center420 Delaware Street SE, MMC 729, Minneapolis, Minnesota 55455612-624-8618 • Fax: [email protected]; [email protected]://www.hsr.umn.edu/rhrc

The Upper Midwest Rural Health Research Center is a partnership that bringstogether the resources and expertise of two research centers with extensiveexperience conducting policy-relevant rural health research and disseminatingresearch findings to federal and state policymakers. The lead organization forthe collaborative effort, the University of Minnesota Rural Health ResearchCenter, is located in the Division of Health Services Research, School of PublicHealth, University of Minnesota. The second partner, the University of NorthDakota Center for Rural Health, is located in the University of North DakotaSchool of Medicine and Health Sciences.

The Center’s mission is to conduct high quality, empirically driven, policy-relevant research that can be disseminated in an effective and timely mannerto help shape the delivery and financing of rural health services. The specificaims of the Center are:

■ To conduct quantitative and qualitative health services research and policyanalysis in a conceptually sound and methodologically rigorous manneron rural health issues that are important to both short- and long-term ruralhealth policy formulation

■ To disseminate the results of original research to local, state, and federalpolicymakers who play key roles in the development of legislation and theadministration of rural health care programs

■ To provide technical assistance to health care policymakers, helping themto understand the unique characteristics of rural health care systems andto implement programs and interventions that address rural health careneeds

■ To train and develop future rural health services researchers by providingopportunities for doctoral student research assistant positions on ourresearch projects.

The Center’s area of concentration is quality of care in rural areas. TheCenter’s projects address key forces that are shaping quality of care andquality improvement in rural areas, including: 1) use of technology andhealth professional staffing to improve quality of care and patient safety; 2)quality measurement and public reporting as tools for improving quality; and3) provision of financial incentives for improving care.

http://www.hsr.umn.edu/rhrc


University of Minnesota Rural Health Research Center

Current PublicationsFor publications prior to 2004, please visit the Center’s website at:http://www.hsr.umn.edu/rhrc/

Working Papers

55. Gregg WR, Knott A & Moscovice I. (2004). Sustaining community health services over time:Models from the Rural Health Outreach Grant Programs.

54. Casey M, Davidson G & Moscovice I. (2004). Access to dental care for rural low income andminority populations.

53. Moscovice I, Wholey D, Klingner J & Knott A. (2004). Measuring rural hospital quality.

52. Casey M & Moscovice I. (2004). Quality improvement strategies and best practices in critical accesshospitals.

51. Stensland J, Davidson G & Moscovice I. (2004). The financial benefits of critical access hospitalconversion for FY 1999 and FY 2000 converters.

Other Publications

Forthcoming

Casey M, Moscovice I, Virnig B & Durham S. (forthcoming). Providing hospice care in ruralareas: Challenges and strategies to address them. American Journal of Hospice and PalliativeMedicine.

Casey M & Moscovice I. (forthcoming). Quality improvement strategies and best practices incritical access hospitals. Journal of Rural Health.

Moscovice I, Wholey D, Klingner J & Knott A. (forthcoming). Measuring rural hospital quality.Journal of Rural Health.

Wholey D, Moscovice I, Hietpas T & Holtzman J. (forthcoming). The environmental context ofpatient safety and medical errors. Journal of Rural Health.

2004

Blewett L, Casey M & Call K. (2004). Improving access to primary care for a growing Latinopopulation: The role of safety net providers in the rural Midwest. Journal of Rural Health,20(3), 237-245.

http://www.hsr.umn.edu/rhrc/

Upper Midwest Rural Health Research Center ■ ��

Casey M, Blewett L & Call K. (2004). Providing health care to Latino immigrants:Community-based efforts in the rural Midwest. American Journal of Public Health,94(10), 1709-1711.

Coburn AF, Wakefield M, Casey M, Moscovice I, Payne SMC & Loux S. (2004). Assuringrural hospital patient safety: What should be the priorities? Journal of Rural Health,20(4), 314-326.

Virnig B, Moscovice I, Kind S & Casey M. (2004). Do rural beneficiaries have limitedaccess to the Medicare hospice benefit? Journal of the American Geriatric Society, 52(5),731-5.

University of North Dakota Center for Rural Health

Current Publications

For publications prior to 2004, please visit the Center’s website at:http://medicine.nodak.edu/crh

2004

Coburn AF, Wakefield M, Casey M, Moscovice I, Payne SMC & Loux S. (2004). Assuringrural hospital patient safety: What should be the priorities? Journal of Rural Health,20(4), 314-326.

Penland JG, Gray JS, Lambert P, Gonzalez J, Wilson EL & Lukaski H.C. (2004).Depression in Northern Plains Indians is associated with physical health and fitness,dietary intakes, food insecurity and cultural identification. The FASEB Journal, 18(4),A516.

Wakefield, M. (2004). Government response: Legislation. In J. Milstead (Ed.), Healthpolicy and politics: A nurse’s guide. (2nd ed.), (pp. 67-88). Sudbury, MA: Jones andBartlett Publishers.

http://medicine.nodak.edu/crh


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WICHE Rural Mental Health Research Center ■ ��

WICHE Rural Mental Health Research CenterCo-Directors: Kathryn R. Rost, Ph.D. and Dennis Mohatt

Western Interstate Commission for Higher EducationMental Health ProgramPO Box 9752, Boulder, Colorado 80301303-541-0311 • Fax [email protected]; [email protected]://www.wiche.edu/mentalhealth/ResearchCenter.asp

The purpose of the WICHE Rural Mental Health Research Center is todevelop and evaluate implementation strategies to promote theadaptation and adoption of evidence-based mental health care in ruralsettings. Implementation strategies will focus on improving care foraffective disorders and serious mental illness. Implementation strategieswill target primary care settings, and the integration of primary carewith available specialty mental health services.

The closely coordinated set of quantitative research projects for 2004-2005 include:

■ Identifying at-risk areas within rural America to target fordepression care model adoption

■ Determining whether and why existing care models differentiallyimprove depression treatment in rural and urban populations

■ Exploring promising hospitalization prevention strategies whichhave the potential to provide more funding for outpatient specialtycare.

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Current PublicationsFor publications prior to 2004, please visit the Center’s website at:http://www.wiche.edu/mentalhealth/ResearchCenter.asp

Working Papers

Fortney J, Pyne J, Edlund M, Robinson D, Mittal D & Henderson K. Design and implementation ofthe Telemedicine Enhanced Antidepressant Management (TEAM) study.

Fortney J, Steffick D, Burgess J, Maciejewsk M & Petersen L. Are primary care services a substituteor complement for specialty and inpatient services?

Rost K, Dickinson LM, Fortney J & Coyne J. The relationship of depression treatment qualityindicators to employee absenteeism, mental health services research.

Other Publications

Forthcoming

Fortney J, Maciejewski M, Warren J & Burgess J. (forthcoming). Does improving geographicaccess to VA primary care services impact patients’ patterns of utilization and costs? Inquiry.

Pyne JM, Rost KM, Farahati F, Tripathi S, Smith J, Williams DK, Fortney J & Coyne JC.(forthcoming). One size fits some: The impact of patient treatment attitudes on the cost-effectiveness of a depression primary care intervention. Psychological Medicine.

Fortney J, Mukherjee S, Curran G, Fortney S, Han X & Booth B. (forthcoming). Factorsassociated with perceived stigma for alcohol use and treatment among at-risk drinkers.Journal of Behavioral Health Services & Research.

Pyne JM, Kuc EJ, Schroeder P, Fortney J, Edlund M & Sullivan G. (forthcoming). Relationshipbetween perceived stigma and depression. Journal of Nervous and Mental Disease.

2004

Chumbler N, Fortney J, Cody M & Beck C. (2004). Sense of coherence and mental health serviceutilization: The case of family caregivers of community-dwelling cognitively-impairedseniors. In J. Jacobs Kronenfeld (Ed.), Chronic care, health care systems and services integration.Vol. 22: Research in the sociology of health care (pp. 161-175). Bristol, England: Elsevier, Ltd.


WWAMI Rural Health Research Center ■ ��

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WWAMI Rural Health Research CenterDirector: L. Gary Hart, Ph.D.

Department of Family Medicine, Box 354982University of Washington,Seattle, Washington 98195-4982206-685-0402 • Fax: [email protected]://www.fammed.washington.edu/wwamirhrc

The Washington, Wyoming, Alaska, Montana, Idaho (WWAMI) RuralHealth Research Center (RHRC) is one of eight rural health research centersfunded by the Federal Office of Rural Health Policy to perform policy-oriented research on issues related to rural health care. The WWAMI RHRC,established in 1988, is based in the Department of Family Medicine at theUniversity of Washington School of Medicine and works closely with theUniversity of Washington Center for Health Workforce Studies, otherdepartments and schools, the Washington State Department of Health, andArea Education Centers in the five WWAMI states (Washington, Wyoming,Alaska, Montana, and Idaho).

Major areas of inquiry at the WWAMI RHRC are:

■ Training and supply of rural health care providers and the content andoutcomes of the care they provide

■ Availability and quality of care for rural women and children, includingobstetric and perinatal care

■ Access to high-quality care for vulnerable and minority ruralpopulations.

The WWAMI Rural Health Research Center conducts its studies in thecontext of the changing health care environment.

http://www.fammed.washington.edu/wwamirhrc


Current PublicationsFor publications prior to 2004, please visit the Center’s website at:http://www.fammed.washington.edu/wwamirhrc

Working Papers

94. Patterson DG & Skillman SM (2004). Health professions education in Washington State: 1996-2004program completion statistics. WWAMI Center for Health Workforce Studies.

93. Skillman SM, Andrilla CHA, Hutson T, Deacon H &Praseuth T. (2004). Washington Statehospitals: results of 2003/04 workforce survey. WWAMI Center for Health Workforce Studies.

92. Patterson DG, Skillman SM & Hart LG. (forthcoming). Washington State’s dental hygienistworkforce through 2020: Influential factors and available data. WWAMI Center for HealthWorkforce Studies.

91. Skillman SM, Palazzo L, Keepnews D & Hart LG. (forthcoming). Characteristics of registerednurses in rural vs. urban areas: Implications for strategies to alleviate nursing shortages in the UnitedStates. WWAMI Center for Health Workforce Studies.

90. Patterson DG, Skillman SM & Hart LG. (forthcoming). Washington State’s pharmacist workforcethrough 2020: Influential factors and available data. WWAMI Center for Health WorkforceStudies.

89. Patterson DG, Skillman SM & Hart LG. (2004). Washington State’s radiographer workforcethrough 2020: Influential factors and available data. WWAMI Center for Health WorkforceStudies.

88. Dobie SA, Hagopian A, Kirlin BA & Hart LG. (forthcoming). Wyoming physicians offersignificant amounts of safety net care in their communities.

87. Jackson JE, Doescher MP & Hart LG. (2004). Obesity prevalence in rural counties: A nationalstudy.

86. Hollow WB, Patterson DG, Olsen PM & Baldwin LM. (2004). American Indians and AlaskaNatives: How do they find their path to medical school? WWAMI Center for Health WorkforceStudies.

78. Baldwin LM, et al. (forthcoming). Access to specialty health care for rural American Indians intwo states.

77. Thompson MJ, Lynge D, Larson EH & Tachawachira P. (2004). Characterizing the generalsurgery workforce in rural America.


WWAMI Rural Health Research Center ■ ��

Other Publications

Forthcoming

Hart LG, Larson EH & Lishner DM. (in press). Rural definitions for health policy andresearch. American Journal of Public Health.

Thompson MJ, Lynge D, Larson EH & Tachawachira P. (in press). Characterizing the generalsurgery workforce in rural America. Archives of General Surgery.

Monographs

Hart LG, Norris TE, Larson EH, Lishner DM, Schneeweiss R & Rosenblatt RA. (forthcoming).Pathways to rural practice: A chartbook of family medicine residency training locationsand characteristics.

2004

Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N & Chan L. (2004). Quality of carefor acute myocardial infarction in rural and urban U.S. hospitals. Journal of Rural Health,20(2), 99-108.

Benedetti TJ, Baldwin LM, Andrilla CHA & Hart LG. (2004). The productivity of WashingtonState’s obstetrician-gynecologist workforce: Does gender make a difference? Obstetrics andGynecology, 103(3), 499-505.

Chan L, Hart LG, Ricketts TC & Beaver SK. (2004). An analysis of Medicare’s incentivepayment program for physicians in health professional shortage areas. Journal of RuralHealth 20(2), 109-117.

Hagopian A, Thompson MJ, Kaltenbach E & Hart LG. (2004). The role of internationalmedical graduates in America’s small rural critical access hospitals. Journal of RuralHealth, 20(1), 52-58.

Rosenblatt RA. (2004). A view from the periphery- health care in rural America. New EnglandJournal of Medicine, 2(2), 1049-1051.

Sulzbacher S, Mas J, Larson EH & Shurtleff DB. (2004). Pediatric telehealth consultation torural schools and clinics in the Pacific Northwest. Journal of Special Education Technology.19(1), 35-41.


V

VV

Alphabetical Listing of Projects ■ ��

�

�

�

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Alphabetical Listing of Projects

AAccess to Cancer Services for Rural Colorectal Cancer (CRC) Medicare Patients:

A Multi-State Study � p� �

Access to Health Care for Young Rural Medicaid Beneficiaries � p� ��

Access to Physician Care for the Rural Medicare Elderly � p� ��

Access to State-of-the-Art Hospice Care for Rural and MinorityHospice Users � p� ��

Advantages and Disadvantages of Hospital-Based Emergency Medical Servicesin Rural Areas � p� ��

Analysis of 2004-2005 State Flex Grant Plans � p� �

Analyzing the Relationships among Critical Access Hospital Financial Status,Organizational Linkages, and Scope of Services � p� ��

Assessing Demand and Capacity for Behavioral Health Services inNorthern Minnesota � p� �

Assessing the Community Impact of the MMA � p� ��

Assessment of Small Rural Hospital Activities to Report Medication Errors � p� �

Attention from the Top? Roles of State Offices of Rural Health Policy inPreparing for Bioterrorism and Other Health System Emergencies � p� �

B-CBreast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America:

Does Proximity to Metropolitan Area Matter? � p� ��

Burden of Chronic Illness Among Rural Residents: A National Study � p� ��

Chartbook of Family Practice Graduate Medical Education Programs inRural America � p� ��

Chronic Disease Management in Rural Areas: Examination of Medicare andMedicaid Managed Care Programs � p� ��

Colorectal Cancer Care Variation in Vulnerable Elderly � p� ��

Community Impact Assessment � p� ��

Critical Access Hospital Conversion Tracking and QuarterlyE-mail Surveys � p� �

D-FDatabase for Rural Health Research in Progress � p� �

Describing Geographic Access to Physicians in Rural America UsingStatistical Applications GIS � p� �

Developing a Quality Performance Measurement System forCritical Access Hospitals � p� ��

Development of a New Methodology for Dental Health ProfessionalShortage Area Designation � p� ��

Diabetes and Hypertension in Rural Hispanics � p� ��

Differential Effectiveness of Enhanced Depression Treatment for Rural andUrban Primary Care Patients � p� �

Disability Burdens Among Rural and Urban Older Americans � p� ��

Alp

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ng

Part 3: Indexes


Do Communities Make a Difference in Access? A National Study � p�

Effects of Alcohol Use on Educational Attainment and Employmentin Rural Youth � p� �

Effects of Uninsurance During the Preceding 10 Years on Health Status ofRural Working Age Adults � p� ��

Estimated Mental Health Care Utilizations in Rural Areas � p� �

Evaluating Need for Assistance Criteria and Weighting of Overall Criteria in theRequirements of Funding New Start and Grant Applicationsfor Health Centers � p� �

Evaluation of New Hampshire’s Rural Hospital Flexibility Program � p� ��

Evaluation of the RWJ/HRSA Demonstration Project “Creating an Integrated OutreachSystem to Isolated Colonia Residents in Hidalgo County, Texas” � p� ��

Examining the Applicability of the AHRQ’s Inpatient Quality Indicators to RuralHospitals and the Implications of the Relationship Between the Indicators andFinancial Measures for Medicare Payment Policies � p� ��

Financial Performance Measures of Critical Access Hospitals � p� ��

H-LHealth Insurance Dynamics of Uninsured Rural Families � p� ��

How Rural Hospitals Are Meeting the Needs of LimitedEnglish Proficiency Patients � p� ��

Identifying At-Risk Rural Areas for Targeting Enhanced Depression Treatment � p� �

Impact of Bioterrorism on Rural Mental Health Needs � p� �

Impact of Declining Access to Obstetric Services � p� ��

Impact of Health Insurance Coverage on Native Elder Health: Implications forAddressing the Health Care Needs of Rural American Indian Elders � p� �

Impact of Mental and Emotional Stress on Rural Employment Patterns � p�

Impact of the Home Health PPS on Access in Rural America � p� ��

Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey � p� ��

Improvement in the Quality of Care for Acute Myocardial Infarction (AMI):Have Rural Hospitals Followed National Trends? � p� ��

Investments in Health Information Technology by Rural Hospitals � p� ��

Is Medicare Beneficiary Access to Primary Care Physicians at Risk? � p� �

Is Rural Residency Training of Family Physicians an Endangered Species?An Interim Follow-up to the 1999 National BBA Study � p� ��

Long Term Trends in Characteristics of the Rural Nurse Workforce:A National Health Workforce Study � p� ��

M-NMaine Mental Health Evidence-Based Practice Planning Initiative � p� �

Medicaid Budget Cuts and Long-Term Care Supplement � p� ��

Medicaid Budget Cuts: Effects on Rural Nursing Homes and Rural Elderlyand Disabled � p� ��

Medicare Beneficiary Outcomes in Rural and Urban Home Health Agencies � p� �

Mental Health Encounters in Critical Access Hospital Emergency Rooms:A National Survey � p� �

Mental Health Risk Factors, Unmet Needs and Provider Availabilityfor Rural Children � p� �

Mental Health Services: The Effect of Variations in State Policies � p�

Monitoring Medicare Hospital Outpatient Payments: Trends and Evidence ofImpacts of Payment Policy � p� �

Alphabetical Listing of Projects ■ ��

National Changes in Physician Supply � p� ��

National Study of Home Health Care Access in Rural America � p� �

National Study of Rural Medicaid Disease Management � p� �

National Study of Rural-Urban Differences in Use of Home Oxygen forChronic Obstructive Lung Disease: Are Rural Medicare BeneficiariesDisadvantaged? � p� �

National Study of Substance Abuse Prevalence & Treatment Services inRural Areas � p�

National Trends in the Perinatal and Infant Health Care of Rural andUrban American Indians (AIs) and Alaska Natives (ANs) � p� ��

Nationwide Analysis of New Entrants into Medicare+Choice Demonstrations � p� �

Native Elder Care Needs Assessment: Development of a Long Term CarePlanning Tool Kit � p� ��

North Carolina Rural Health Guide � p� �

O-ROptions for Structuring Disproportionate Share (DSH) Payments to Account for

Uncompensated Care: Impact on Rural Hospitals � p� ��

Patient Bypass Behavior and Critical Access Hospitals: Implications forPatient Retention � p� ��

Pay for Performance and Quality Improvement in Rural Hospitals � p� ��

Pharmaceutical Data Validity in Estimating Rural Population Health � p� �

Post-Acute Care: A Rural and Urban Comparison � p�

Poverty, Parental Stress, and Violent Disagreements in the Home AmongRural Families � p� �

Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehiclefor Expanding Health Insurance to Rural Uninsured � p� �

Preventing Hospitalization in Depressed Rural Patients � p� �

Public Health System Performance Measurement: Are Standards Applicable toRural Communities � p� �

Quality of Women’s Care in Rural Health Clinics: A National Analysis � p� �

Refining and Field Testing a Relevant Set of Quality Measures forRural Hospitals � p� ��

Role of Intensive Care Units in Critical Access Hospitals � p� �

Rural Access and State Loan Repayment for Dentists � p� �

Rural and Urban Differences in Utilization of Formal Home Care � p� ��

Rural Health Center Expansion and Recruitment Survey � p� �

Rural Healthy People 2010 Expansion: Access to Long-Term Care and RehabilitationServices, Educational and Community-Based Programs, and Public HealthInfrastructure � p� ��

Rural Hospital Flexibility Performance Monitoring Project � p� ��

Rural Minority Health: A Comprehensive Assessment � p� ��

Rural Public Health Structure and Infrastructure � p� �

Rural Quality Improvement Focus on Diabetes � p� ��

Rural Safety Net Provision and Hospital Care in 10 States � p� �

Rural-Urban Commuting Area (RUCA) Development Project:Demographic Description and Frontier Enhancement � p� ��

Rural-Urban Physician Payment Differences Across the Nation:Methodological Changes � p� �


V

VV

S-WSoutheast Regional Center for Health Workforce Studies � p� ��

Special Study of EMS Issues � p� ��

State Child Health Insurance Program (S-CHIP) and Access to Medical TransportationProgram Services � p� �

State of Rural Health Provider Organizations and Health Professional Shortages � p� �

Stay or Leave: Evidence from a Cohort of Young Rural Physicians � p� �

Successful Implementation of Medication Safety Initiatives in Rural Hospitals:The Role of Pharmacists and Technology � p� ��

Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals, 1996-2003 � p� �

Trends in Uninsurance Among Rural Minority Children � p� ��

Tribal Long-Term Care: Barriers to Best Practices in Policy and Programming for aNational Sample of Rural Tribes � p� ��

Uninsurance and Welfare Reform in Rural America � p� ��

University of Washington Center for Health Workforce Studies � p� ��

Urban and Rural Differences in Access to Care and Treatment for Medicare Beneficiarieswith Cancer � p� �

Using Program Logic Models to Monitor the Performance of State Flex Programs � p� ��

Which Training Programs Produce Rural Physicians? A National HealthWorkforce Study � p� ��

Why Are Health Care Costs Increasing and Is There a Rural Differential inNational Data? � p� ��

List of Projects by Center ■ ��

Project List by Center

Maine Rural Health Research CenterDirector: David Hartley, Ph.D.Deputy Director: Andrew F. Coburn, Ph.D.

Institute for Health Policy, Muskie School of Public ServiceUniversity of Southern MainePO Box 9300, Portland, Maine 04104-9300207-780-4430 ï Fax [email protected]; [email protected]://muskie.usm.maine.edu/ihp/ruralhealth

Topic of Concentration: Rural Behavioral Health

■ Database for Rural Health Research in Progress

■ Evaluation of New Hampshire’s Rural Hospital Flexibility Program

■ Health Insurance Dynamics of Uninsured Rural Families

■ The Impact of Mental and Emotional Stress on Rural Employment Patterns

■ Maine Mental Health Evidence-Based Practice Planning Initiative

■ Mental Health Encounters in Critical Access Hospital Emergency Rooms:A National Survey

■ National Study of Substance Abuse Prevalence and TreatmentServices in Rural Areas

Flex Monitoring Team Projects:

■ Analysis of 2004-2005 State Flex Grant Plans

■ Special Study of EMS Issues

■ Using Program Logic Models to Monitor the Performance of StateFlex Programs

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http://muskie.usm.maine.edu/ihp/ruralhealth


NORC Walsh Center for Rural Health AnalysisDirector: Curt D. Mueller, Ph.D.Associate Director: Julie A. Schoenman, Ph.D.

National Opinion Research Center (NORC)7500 Old Georgetown Road, Suite 620, Bethesda, Maryland [email protected]://www.norc.uchicago.edu/issues/health6.asp

Topic of Concentration: Impact of Medicare Policies on Rural Communities

■ Advantages and Disadvantages of Hospital-based Emergency Medical Servicesin Rural Areas

■ Attention from the Top? Roles of State Offices of Rural Health Policy inPreparing for Bioterrorism and Other Health System Emergencies

■ The Impact of Declining Access to Obstetric Services

■ Impact of the Home Health PPS on Access in Rural America

■ Investments in Health Information Technology by Rural Hospitals

■ Medicare Beneficiary Outcomes in Rural and Urban Home Health Agencies

■ Monitoring Medicare Hospital Outpatient Payments: Trends and Evidence onImpacts of Payment Policy

■ Options for Structuring Disproportionate Share (DSH) Payments to Account forUncompensated Care: Impact on Rural Hospitals

■ Post-Acute Care: A Rural and Urban Comparison

■ Public Health System Performance Measurement: Are Standards Applicable toRural Communities?

■ Stay or Leave: Evidence from a Cohort of Young Rural Physicians

http://www.norc.uchicago.edu/issues/health6.asp


North Carolina Rural Health Research andPolicy Analysis CenterDirector: Rebecca T. Slifkin, Ph.D.

Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill725 Airport Road CB 7590, Chapel Hill, NC 27599-7590919-966-5541 ï Fax: [email protected]://www.shepscenter.unc.edu

Topic of Concentration: Federal Insurance Programs (Medicare and Medicaid) andTheir Effect on Rural Populations and Providers

■ Access to Health Care for Young Rural Medicaid Beneficiaries

■ Describing Geographic Access to Physicians in Rural America Using StatisticalApplications in GIS

■ Development of a New Methodology for Dental Health Professional ShortageArea Designation

■ Evaluating Need for Assistance Criteria and Weighting of Overall Criteria in theRequirements of Funding New Start and Grant Applications for Health Centers

■ Impact of the Medicaid Budget Crisis on Rural Communities:A 50-State Survey

■ The North Carolina Rural Health Guide

■ Premium Assistance Programs: Exploring Public-Private Partnerships as aVehicle of Expanding Health Insurance to Rural Uninsured. (Qualitative Project)

■ The Role of Intensive Care Units in Critical Access Hospitals

■ Southeast Regional Center for Health Workforce Studies

■ Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals,1996 -2003


■ Community Impact Assessment

■ Critical Access Hospital Conversion Tracking and QuarterlyE-mail Surveys

■ Financial Performance Measures of Critical Access Hospitals

http://www.shepscenter.unc.edu


RUPRI Center for Rural Health Policy AnalysisDirector: Keith J. Mueller, Ph.D.

University of Nebraska Medical Center984350 Nebraska Medical CenterOmaha, NE 68198-4350402-559-5260Fax: [email protected]://www.rupri.org/healthpolicy

Topic of Concentration: Medicare: Impact of Payment and Quality Policy on theDelivery of Health Care in Rural Areas

■ Assessing the Community Impact of the Medicare Prescription Drug,Improvement, and Modernization Act of 2003 (MMA)

■ Assessment of Small Rural Hospital Activities to Report Medication Errors

■ Do Communities Make a Difference in Access? A National Study

■ Establishing a Fair Payment for Rural Physicians

■ Examining the Applicability of AHRQ’s Inpatient Quality Indicators to RuralHospitals and the Implications of the Relationship Between the Indicators andFinancial Measures for Medicare Payment Policies

■ Is Medicare Beneficiary Access to Primary Care Physicians at Risk?

■ Nationwide Analysis of New Entrants into Medicare+Choice Demonstrations

■ Rural Quality Improvement Focus on Diabetes

■ Rural-Urban Physician Payment Differences Across the Nation:Methodological Changes

■ Uninsurance and Welfare Reform in Rural America

■ Why Are Health Care Costs Increasing and Is There a Rural Differential inNational Data?

http://www.rupri.org/healthpolicy


South Carolina Rural Health Research CenterDirector: Janice C. Probst, Ph.D.Deputy Director: Charity Moore, Ph.D.

Arnold School of Public HealthUniversity of South Carolina220 Stoneridge Drive, Suite 204Columbia, SC 29210803-251-6317 ï Fax: [email protected]; [email protected]://rhr.sph.sc.edu

Topic of Concentration: Health Disparities

■ Diabetes and Hypertension in Rural Hispanics

■ Disability Burdens among Rural and Urban Older Americans

■ Effects of Alcohol Use on Educational Attainment and Employment in RuralYouth

■ Effects of Uninsurance During the Preceding 10 Years on Health Status of RuralWorking Age Adults

■ Estimated Mental Health Care Utilizations in Rural Areas

■ How Rural Hospitals Are Meeting the Needs of Limited-English ProficiencyPatients

■ Mental Health Risk Factors, Unmet Needs and Provider Availability for RuralChildren

■ Poverty, Parental Stress, and Violent Disagreements in the Home among RuralFamilies

■ Rural Health Center Expansion and Recruitment Survey (with WWAMI)

■ Rural Minority Health

■ Trends in Uninsurance Among Rural Minority Children



Southwest Rural Health Research CenterDirector: Catherine Hawes, Ph.D.Associate Director: Larry Gamm,Ph.D.

School of Rural Public Health, 1266 TAMUTexas A&M University System Health Science CenterCollege Station, Texas 77843-1266979-458-0653 or 979-458-0081 (Hawes) • Fax: [email protected]; [email protected]://www.srph.tamushsc.edu/centers/srhrc

FYs 2001-2004

■ Chronic Disease Management in Rural Areas: Examination of Medicare andMedicaid Managed Care Programs

■ Evaluation of the RWJ/HRSA Demonstration Project “Creating an IntegratedOutreach System to Isolated Colonia Residents in Hidalgo County, Texas”

■ Medicaid Budget Cuts: Effects on Rural Nursing Homes and Rural Elderly andDisabled

■ Medicaid Budget Cuts and Long-Term Care Supplement

■ Mental Health Services: The Effect of Variations in State Policies

■ Rural Healthy People 2010 Expansion: Access to Long-Term Care andRehabilitation Services, Educational and Community-Based Programs, andPublic Health Infrastructure

■ S-CHIP and Access to Medical Transportation Program Services

■ The State of Rural Health Provider Organizations and Health ProfessionalShortages

http://www.srph.tamushsc.edu/centers/srhrc


Upper Midwest Rural HealthResearch CenterDirector: Ira Moscovice, Ph.D.Deputy Director: Mary Wakefield, Ph.D., R.N.

University of Minnesota Rural Health Research Center420 Delaware Street SE, MMC 729, Minneapolis, Minnesota 55455612-624-8618 • Fax: [email protected]; [email protected]://www.hrs.umn.edu/rhrc

Topic of Concentration: Quality of Care in Rural Areas

■ The Impact of Health Insurance Coverage on Native Elder Health: Implications forAddressing the Health Care Needs of Rural American Indian Elders

■ Pay for Performance and Quality of Care in Rural Hospitals

■ Successful Implementation of Medication Safety Initiatives in Rural Hospitals: TheRole of Pharmacists, and Technology

Minnesota Rural Health Research Center:

■ Access to State of the Art Hospice Care for Rural and Minority Hospice Users

■ Assessing Demand and Capacity for Behavioral Health Services in NorthernMinnesota

■ Refining and Field Testing a Relevant Set of Quality Measures for Rural Hospitals


■ Analyzing the Relationships among Critical Access Hospital FinancialStatus, Organizational Linkages, and Scope of Services

■ Developing a Quality Performance Measurement System for CriticalAccess Hospitals

http://www.hrs.umn.edu/rhrc


WICHE Rural Mental Health Research CenterDirector: Kathryn Rost, Ph.D.Co-Director: Dennis Mohatt, M.A.

Western Interstate Commission for Higher Education9414 East Arbor DriveEnglewood, CO 80111303-221-3904 • Fax: [email protected]; [email protected]://www.wiche.edu/mentalhealth/ResearchCenter.asp

Topic of Concentration: Mental Health

■ Differential Effectiveness of Enhanced Depression Treatment for Rural and UrbanPrimary Care Patients

■ Identifying At-Risk Areas Within Rural America to Target for EnhancedDepression Treatment

■ Preventing Hospitalization in Depressed Rural Patients



WWAMI Rural Health Research CenterDirector: L. Gary Hart, Ph.D.

Department of Family Medicine, Box 354982University of Washington,Seattle, Washington 98195-4982206-685-0402 • Fax: [email protected]://www.fammed.washington.edu/wwamirhrc

Topic of Concentration: National Rural Health Workforce Research

■ Access to Cancer Services for Rural Colorectal Cancer (CRC) Medicare Patients:A Multi-State Study

■ Access to Physician Care for the Rural Medicare Elderly

■ Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: DoesProximity to a Metropolitan Area Matter?

■ The Burden of Chronic Illness among Rural Residents: A National Study

■ Chartbook of Family Practice Graduate Medical Education Programs in RuralAmerica

■ Colorectal Cancer Care Variation in Vulnerable Elderly

■ Improvement in the Quality of Care for Acute Myocardial Infarction (AMI): HaveRural Hospitals Followed National Trends?

■ Is Rural Residency Training of Family Physicians an Endangered Species? AnInterim Follow-up to the 1999 National BBA Study

■ Long-Term Trends in Characteristics of the Rural Nurse Workforce 1980 - 2000: ANational Health Workforce Study

■ National Changes in Physician Supply

■ National Study of Rural-Urban Differences in Use of Home Oxygen for ChronicObstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?

■ National Trends in the Perinatal and Infant Health Care of Rural and UrbanAmerican Indians and Alaska Natives

■ Rural Health Center Expansion and Recruitment Survey (with South CarolinaRural Health Research Center)

■ Rural-Urban Commuting Area (RUCA) Development Project: DemographicDescription and Frontier Enhancement

■ University of Washington Center for Health Workforce Studies

■ Which Training Programs Produce Rural Physicians? A National Health WorkforceStudy



Individual Grantees:

Allery, Alan, MHAUniversity of North Dakota

❏ Native Elder Care Needs Assessment: Development of a Long Term CarePlanning Tool Kit

Cossman, Ronald, Ph.D.Mississippi State University

❏ Pharmaceutical Data Validity in Estimating Rural HealthEdwards, Joellen B., Ph.D., RN,East Tennessee State University

❏ Quality of Women’s Care in Rural Health Clinics: A National AnalysisGehshan, ShellyNational Conference of State Legislatures

❏ Rural Access and State Loan Repayment for DentistsGoins, R. Turner, Ph.D.West Virginia University

❏ Tribal Long-Term Care: Barriers to Best Practices in Policy and Programmingfor a National Sample of Rural Tribes

Ketsche, Patricia, Ph.D.Georgia State University Research Foundation

❏ Rural Safety Net Provision and Hospital Care in 10 StatesLiu, Jiexin (Jason), Ph.D.West Virginia Research Corporation

❏ Patient Bypass Behavior and Critical Access Hospitals:Implications for Patient Retention

Matthews, Trudi L., M.A.,The Council of State Governments

❏ National Study of Rural Medicaid Disease ManagementMcAuley, William J., Ph.D.,Agency for Healthcare Research and Quality

❏ Rural and Urban Differences in Utilization of Formal Home CareShugarman, Lisa, Ph.D.,Rand Corporation

❏ Urban and Rural Differences in Access to Care and Treatment for MedicareBeneficiaries with Cancer

Tsao, Jennie C. I., Ph.D.,University of California, Los Angeles

❏ Impact of Bioterrorism on Rural Mental Health NeedsVirnig, Beth Anne, Ph.D.University of Minnesota

❏ National Study of Home Health Access in Rural AmericaWellever, Anthony, M.A.,Kansas Health Institute

❏ Rural Public Health Structure and Infrastructure

List of Projects by Funding Source ■ ��

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List of Projects by Funding Source

■ American Cancer Society❏ Access to State-of-the-Art Hospice Care for Rural and Minority

Hospice Users

■ Bureau of Health Professions, Health Resources and ServicesAdministration❏ Southeast Regional Center for Health Workforce Studies❏ University of Washington Center for Health Workforce Studies

■ Bureau of Rural Health and Primary Care, Department of Healthand Human Services❏ Evaluation of New Hampshire’s Rural Hospital Flexibility Program

■ Centers for Medicare and Medicaid Services❏ Refining and Field Testing a Relevant Set of Quality Measures for

Rural Hospitals

■ Federal Office of Rural Health Policy, HRSA❏ Access to Cancer Services for Rural Colorectal Cancer (CRC)

Medicare Patients: A Multi-State Study❏ Access to Health Care for Young Rural Medicaid Beneficiaries❏ Access to Physician Care for the Rural Medicare Elderly❏ Advantages and Disadvantages of Hospital-Based Emergency

Medical Services in Rural Areas❏ Analysis of 2004-2005 State Flex Grant Plans❏ Analyzing the Relationships among Critical Access Hospital

Financial Status, Organizational Linkages, and Scope of Services❏ Assessing the Community Impact of the MMA❏ Assessment of Small Rural Hospital Activities to Report

Medication Errors❏ Attention from the Top? Roles of State Offices of Rural Health

Policy in Preparing for Bioterrorism and Other Health SystemEmergencies

❏ Breast, Cervical, Colorectal, and Prostate Cancer Screening in RuralAmerica: Does Proximity to Metropolitan Area Matter?

Fu

nd

ing

So

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e


❏ Burden of Chronic Illness Among Rural Residents: A National Study❏ Chartbook of Family Practice Graduate Medical Education Programs

in Rural America❏ Chronic Disease Management in Rural Areas: Examination of Medicare and

Medicaid Managed Care Programs❏ Community Impact Assessment❏ Critical Access Hospital Conversion Tracking and Quarterly E-mail Surveys❏ Database for Rural Health Research in Progress❏ Describing Geographic Access to Physicians in Rural America Using

Statistical Applications GIS❏ Developing a Quality Performance Measurement System for

Critical Access Hospitals❏ Diabetes and Hypertension in Rural Hispanics❏ Differential Effectiveness of Enhanced Depression Treatment for Rural and

Urban Primary Care Patients❏ Disability Burdens Among Rural and Urban Older Americans❏ Do Communities Make a Difference in Access? A National Study❏ Effects of Alcohol Use on Educational Attainment and Employment in

Rural Youth❏ Effects of Uninsurance During the Preceding 10 Years on Health Status of

Rural Working Age Adults❏ Estimated Mental Health Care Utilizations in Rural Areas❏ Evaluating Need for Assistance Criteria and Weighting of Overall Criteria

in the Requirements of Funding New Start and Grant Applications forHealth Centers

❏ Examining the Applicability of the AHRQ’s Inpatient Quality Indicators toRural Hospitals and the Implications of the Relationship Between theIndicators and Financial Measures for Medicare Payment Policies

❏ Financial Performance Measures of Critical Access Hospitals❏ Health Insurance Dynamics of Uninsured Rural Families❏ How Rural Hospitals Are Meeting the Needs of Limited English

Proficiency Patients❏ Identifying At-Risk Rural Areas for Targeting Enhanced Depression Treatment❏ Impact of Bioterrorism on Rural Mental Health Needs❏ Impact of Declining Access to Obstetric Services❏ Impact of Health Insurance Coverage on Native Elder Health:

Implications for Addressing the Health Care Needs of Rural AmericanIndian Elders

❏ Impact of Mental and Emotional Stress on Rural Employment Patterns❏ Impact of the Home Health PPS on Access in Rural America❏ Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey


❏ Improvement in the Quality of Care for Acute Myocardial Infarction (AMI):Have Rural Hospitals Followed National Trends?

❏ Investments in Health Information Technology by Rural Hospitals❏ Is Medicare Beneficiary Access to Primary Care Physicians at Risk?❏ Is Rural Residency Training of Family Physicians an Endangered Species?

An Interim Follow-up to the 1999 National BBA Study❏ Long Term Trends in Characteristics of the Rural Nurse Workforce:

A National Health Workforce Study❏ Medicaid Budget Cuts and Long-Term Care Supplement❏ Medicaid Budget Cuts: Effects on Rural Nursing Homes and Rural Elderly

and Disabled❏ Medicare Beneficiary Outcomes in Rural and Urban Home Health Agencies❏ Mental Health Encounters in Critical Access Hospital Emergency Rooms:

A National Survey❏ Mental Health Risk Factors, Unmet Needs and Provider Availability for

Rural Children❏ Mental Health Services: The Effect of Variations in State Policies❏ Monitoring Medicare Hospital Outpatient Payments: Trends and Evidence of

Impacts of Payment Policy❏ National Changes in Physician Supply❏ National Study of Home Health Care Access in Rural America❏ National Study of Rural Medicaid Disease Management❏ National Study of Rural-Urban Differences in Use of Home Oxygen for

Chronic Obstructive Lung Disease: Are Rural Medicare BeneficiariesDisadvantaged?

❏ National Study of Substance Abuse Prevalence & Treatment Services inRural Areas

❏ National Trends in the Perinatal and Infant Health Care of Rural and UrbanAmerican Indians (AIs) and Alaska Natives (ANs)

❏ Nationwide Analysis of New Entrants into Medicare+Choice Demonstration❏ Native Elder Care Needs Assessment: Development of a Long Term Care

Planning Tool Kit❏ Options for Structuring Disproportionate Share (DSH) Payments to Account for

Uncompensated Care: Impact on Rural Hospitals❏ Patient Bypass Behavior and Critical Access Hospitals:

Implications for Patient Retention❏ Pay for Performance and Quality Improvement in Rural Hospitals❏ Pharmaceutical Data Validity in Estimating Rural Population Health❏ Post-Acute Care: A Rural and Urban Comparison❏ Poverty, Parental Stress, and Violent Disagreements in the Home Among

Rural Families


❏ Premium Assistance Programs: Exploring Public-Private Partnerships asa Vehicle for Expanding Health Insurance to Rural Uninsured

❏ Preventing Hospitalization in Depressed Rural Patients❏ Public Health System Performance Measurement: Are Standards Applicable

to Rural Communities❏ Quality of Women’s Care in Rural Health Clinics: A National Analysis❏ Role of Intensive Care Units in Critical Access Hospitals❏ Rural Access and State Loan Repayment for Dentists❏ Rural and Urban Differences in Utilization of Formal Home Care❏ Rural Health Center Expansion and Recruitment Survey❏ Rural Healthy People 2010 Expansion: Access to Long-Term Care and

Rehabilitation Services, Educational and Community-Based Programs, andPublic Health Infrastructure

❏ Rural Hospital Flexibility Performance Monitoring Project❏ Rural Minority Health: A Comprehensive Assessment❏ Rural Public Health Structure and Infrastructure❏ Rural Quality Improvement Focus on Diabetes❏ Rural Safety Net Provision and Hospital Care in 10 States❏ Rural-Urban Commuting Area (RUCA) Development Project: Demographic

Description and Frontier Enhancement❏ Rural-Urban Physician Payment Differences Across the Nation:

Methodological Changes❏ Special Study of EMS Issues Federal Office of Rural Health Policy, HRSA❏ State Child Health Insurance Program (S-CHIP) and Access to Medical

Transportation Program Services❏ State of Rural Health Provider Organizations and Health Professional Shortages❏ Stay or Leave: Evidence from a Cohort of Young Rural Physicians❏ Successful Implementation of Medication Safety Initiatives in Rural Hospitals:

The Role of Pharmacists and Technology❏ Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals,

1996-2003❏ Trends in Uninsurance Among Rural Minority Children❏ Tribal Long-Term Care: Barriers to Best Practices in Policy and Programming

for a National Sample of Rural Tribes❏ Uninsurance and Welfare Reform in Rural America❏ Urban and Rural Differences in Access to Care and Treatment for Medicare

Beneficiaries with Cancer❏ Using Program Logic Models to Monitor the Performance of State Flex Programs


❏ Which Training Programs Produce Rural Physicians? A National HealthWorkforce Study

❏ Why Are Health Care Costs Increasing and Is There a Rural Differential inNational Data?

■ Generation Health Care Initiatives❏ Assessing Demand and Capacity for Behavioral Health Services in

Northern Minnesota

■ Health Resources and Services Administration❏ Development of a New Methodology for Dental Health ProfessionalShortage Area Designation

■ National Cancer Institute❏ Colorectal Cancer Care Variation in Vulnerable Elderly

■ National Institutes of Mental Health❏ Maine Mental Health Evidence-Based Practice Planning Initiative

■ North Carolina Hospital Association (NCHA)❏ North Carolina Rural Health Guide

■ Robert Wood Johnson Foundation❏ Evaluation of the RWJ/HRSA Demonstration Project

“Creating an Integrated Outreach System to Isolated Colonia Residents inHidalgo County, Texas”

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