Maine Rural Health Research Center

Publications

Listed by publication date. You can also view these publications alphabetically.

2008

• Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum (Research & Policy Brief No. 35B)
  Author(s): Jennifer D. Lenardson, John A. Gale
  Date: 02 / 2008
  Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
  This Research & Policy Brief highlights findings from a recent study examining the distribution of substance abuse treatment facilities in rural and urban counties and identifying the type and intensity of services provided. Key findings include:
  • Access to substance abuse treatment is limited in rural areas by fewer treatment beds.
  • Less populated rural areas contain a small proportion of facilities offering a range of core services and varying levels of outpatient and intensive services.
  • Opiod treatment programs are nearly absent in rural areas.

2007

• Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum
  Author(s): Jennifer D. Lenardson, John A. Gale
  Report Number: Working Paper No. 35
  Date: 10 / 2007
  Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
  Considering recent growth in substance abuse among rural populations and the documented scarcity of rural health resources, this study examines the distribution of substance abuse treatment services across the continuum of rural and urban counties, identifying the type and intensity of services provided. Using the 2004 National Survey of Substance Abuse Treatment Services linked to the 2003 Rural-Urban Continuum Codes, we found few substance abuse treatment facilities operating outside of urban and rural adjacent areas and limited availability of intensive services across rural areas. This situation is particularly striking for opioid treatment programs, which are nearly absent in rural areas. The narrow range of services available in rural areas may preclude an individualized treatment approach and long-term follow-up recommended by professional organizations and other experts. The greater proportion of rural-based facilities accepting public payers and providing discounted care may reflect higher rates of uninsurance and underinsurance.
• State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program
  Author(s): John Gale, Jennifer Lenardson, Walt Gregg, Michelle Casey, Indira Richardson, Stephen Rutledge, Rebecca Slifkin
  Report Number: Flex Monitoring Team Briefing Paper No. 15
  Date: 10 / 2007
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Explores activities funded by the Medicare Rural Hospital Flexibility Program (Flex Program) to strengthen the rural health care infrastructure and discusses which activities were considered most successful by State Flex Coordinators. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Rural Inpatient Psychiatric Units Improve Access to Community-Based Mental Health Services, but Medicare Payment Policy a Barrier
  Author(s): Stephenie Loux, David Hartley, David Lambert
  Date: 08 / 2007
  Topics: Health services, Hospitals and clinics, Mental health
  Inpatient Psychiatric Units (IPUs) may not only be an important source of care for rural residents, but may also assist in the development of community-based services and the recruitment of mental health professionals. This study investigates the typical characteristics and admission processes of IPUs in rural hospitals with less than 50 beds, as well as the community-based services available to them when discharging patients. Reasons for developing these IPUs as well as the barriers to opening and operating a rural IPU and factors that have led some to close are also explored.
• Rural Families More Likely to be Uninsured and Have Different Sources of Coverage
  Date: 06 / 2007
  Topic: Health insurance and the uninsured
  Research and policy brief examining patterns of health insurance coverage within rural families and comparing family-level insurance status for rural and urban families.
• Substance Abuse Among Rural Youth: A Little Meth and a Lot of Booze
  Date: 06 / 2007
  Topics: Children, Substance abuse
  Research and policy brief examining substance abuse among rural youth, with rural-urban comparisons methamphetamine, oxycontin, and alcohol abuse.
• State Flex Program at 10 Years: Strengthening Critical Access Hospitals and Rural Communities
  Author(s): John A. Gale, Jennifer Lenardson, Walter R. Gregg, Michelle Casey, Indira Richardson, Stephen Rutledge
  Report Number: Flex Monitoring Team Policy Brief No. 3
  Date: 04 / 2007
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  To understand the priorities and accomplishments of state Flex Grant Programs, members of the Flex Monitoring Team asked Flex Coordinators to identify and discuss their states’ three most successful initiatives in the past two years. Interviews were conducted during February 2007 with Flex Coordinators and State Office of Rural Health staff (SORH) in all 45 states. The listed publication is a policy brief; the full report will be available in the fall of 2007. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Community Impact of Critical Access Hospitals
  Author(s): John A. Gale, Andrew F. Coburn, Victoria Freeman, Walter R. Gregg, Rebecca Slifkin
  Report Number: Policy Brief No. 2
  Date: 02 / 2007
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Discusses the findings of a project to understand the community involvement and impact of Critical Access Hospitals (CAHs) and the Medicare Rural Hospital Flexibility Program (Flex Program). Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Exploring the Community Impact of Critical Access Hospitals
  Author(s): John Gale, Andrew Coburn, Walt Gregg, Rebecca Slifkin, Victoria Freeman
  Report Number: Flex Monitoring Team Briefing Paper No. 14
  Date: 01 / 2007
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Reports on a series of site visits to six diverse rural communities and Critical Access Hospitals (CAHs) to assess the experiences and impact of these hospitals in responding to their community’s health infrastructure needs. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Use of Critical Access Hospital Emergency Rooms by Patients With Mental Health Symptoms
  Author(s): David Hartley, Erika C. Ziller, Stephenie L. Loux, John A. Gale, David Lambert, Anush E. Yousefian
  Citation: Journal of Rural Health, 23(2), 108-115
  Date: 2007
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
  Describes the results of a study investigating the use of critical access hospital (CAH) emergency rooms by patients with mental health problems to understand the role these facilities play in rural mental health needs and the challenges they face.

2006

• Prioritizing Patient Safety Interventions in Small Rural Hospitals
  Author(s): Michelle Casey, Mary Wakefield, Andrew F. Coburn, Ira Moscovice, Stephanie Loux
  Citation: Joint Commission Journal on Quality and Patient Safety, 32(12), 693-702
  Date: 12 / 2006
  Topics: Hospitals and clinics, Quality
  Reports the results of a study seeking to determine if 26 patient safety practices recommended by an expert panel as relevant to rural hospitals would be validated in terms of rural relevance and implementability by administrators and quality managers in small rural facilities in Maine, Minnesota, Montana, North Dakota, Pennsylvania, and Tennessee. This research was supported by funding from the Agency for Healthcare Research and Quality and the Office of Rural Health Policy.
• Integrating Primary Care and Mental Health: Current Practices in Rural Community Health Centers
  Author(s): David Lambert, John Gale
  Citation: Kansas City, MO: National Rural Health Association
  Date: 10 / 2006
  Topics: Federally Qualified Health Centers (FQHCs), Mental health
  Provides information on models for integrating mental health services in rural community health centers, viability of linkages between primary care and mental health providers, resources available, reimbursement, treatment philosophy, diversification, referral and enhancement. Available for purchase.
• Quality and Performance Improvement Grant Activities Under the Flex Program
  Author(s): Jennifer Lenardson, John Gale
  Report Number: Flex Monitoring Team Briefing Paper No. 12
  Date: 08 / 2006
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Quality
  Describes quality and performance improvement activities proposed by states during the 2005 grant year under the Medicare Rural Health Flexibility Program (Flex Program). Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Creating Program Logic Models: A Toolkit for State Flex Programs
  Author(s): John Gale, Stephenie Loux, Andrew Coburn
  Date: 04 / 2006
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Provide states with a tool for planning, managing, reporting on, and assessing their Flex Program goals, activities, and accomplishments; assistance in identifying and defining measurable outcomes; information linking state-level Flex Program strategies to specific and measurable outcomes; and a consistent program-reporting framework to convey results to both internal and external stakeholders. The Program Logic Model (PLM) Toolkit is organized according to the steps in the PLM development process and guides the user through each section. Included in the Toolkit is an overview of PLMs, their component parts, and the application of the PLM framework to the planning, implementation, and evaluation of the Flex Program. The bulk of the Toolkit provides a step-by-step approach to developing a Program Logic Model. The final section of the Toolkit lists resources for additional information on PLMs. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Review of State Flex Program Plans, 2004-2005
  Author(s): Stephenie Loux, John Gale, Anush Yousefian, Andrew Coburn, Walter Gregg
  Report Number: Flex Monitoring Team Briefing Paper No. 10
  Date: 03 / 2006
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Examines the objectives and project activities proposed by states in their Medicare Rural Hospital Flexibility Program (Flex Program) grant applications for Fiscal Year 2004 to strengthen the rural healthcare infrastructure in their states. Highlights recent trends in State Flex Program planning, development, and implementation. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Emergency Medical Services (EMS) Activities Funded by the Medicare Rural Hospital Flexibility Program
  Author(s): P. Daniel Patterson, John A. Gale, Stephenie L. Loux, Anush E. Yousefian, Rebecca Slifkin
  Report Number: Flex Monitoring Team Briefing Paper No. 8
  Date: 02 / 2006
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS)
  Describes the EMS related activities that the 45 states receiving funding from the Medicare Rural Hospital Flexibility (Flex) Program proposed to conduct in fiscal year 2004-2005. Since the first full year of funding, the number and range of EMS improvement activities proposed has increased substantially states' proposals contained 239 documented EMS improvement activities. Of these, 40% focused on the Integration of Health Services attribute, 13% on Human Resource challenges, and 13% on Education Systems. Continued support of activities begun prior to 2004 was common. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Rural Health Research in Progress in the Rural Health Research Centers Program, 10th Edition
  Author(s): Karen B. Pearson (Ed.)
  Citation: Portland, ME: University of Southern Maine, Edmund S. Muskie School of Public Service, Institute for Health Policy, Maine Rural Health Research Center
  Date: 02 / 2006
  Topic: Health policy
  Annual monograph providing policymakers with a concise source of rural health services research currently underway in the Rural Health Research Centers funded by the Office of Rural Health Policy. Provides a context for legislation current and proposed that affects rural health services and populations. A summary report booklet is provided to the federal Office of Rural Health Policy prior to the full printing of the monograph. The summary booklet is also distributed to members of the Senate Rural Caucus and the House Rural Health Care Coalition.
• Mental Health Care in Rural Communities: the Once and Future Role of Primary Care
  Author(s): John A.Gale, David Lambert,
  Citation: North Carolina Medical Journal, 67(1), 66-70
  Date: 2006
  Topics: Health services, Mental health
  Discusses issues related to the delivery of mental health services in the United States. Addresses how these issues complicate the delivery of services in rural areas. Offers an argument for integrating primary care and mental health in rural areas.
• Out-Of-Pocket Health Spending And The Rural Underinsured
  Author(s): Erika C. Ziller, Andrew F. Coburn, Anush E. Yousefian
  Citation: Health Affairs, 25(6), 1688-1699
  Date: 2006
  Topics: Health insurance and the uninsured, Rural statistics and demographics
  Estimates underinsurance rates among privately insured rural residents and the characteristics associated with rural underinsurance.
• Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices
  Author(s): Donald Sawyer, John Gale, David Lambert
  Citation: Waite Park, MN: National Association of Rural Mental Health
  Date: 2006
  Topics: Frontier health, Mental health, Substance abuse, Telehealth
  Discusses barriers to mental and behavioral health service delivery in rural America. Includes model programs and model policy strategies for rural mental and behavioral health care delivery. Also discusses the roles that telehealth and that the State Offices of Rural Health should play in service delivery.
• Rural Hospitals and Long-Term Care: the Challenges of Diversification and Integration Strategies
  Author(s): Andrew F. Coburn, Stephanie Loux, E.J. Bolda
  Citation: In R. T. Goins, & J. A. Krout (Eds.), Service delivery to rural older adults: Research, policy, and practice. (pp. 103-122). New York, NY: Springer Publishing Co.
  Date: 2006
  Topics: Hospitals and clinics, Long term care
  
• Rural Residents More Likely to be Underinsured
  Author(s): Erika Ziller
  Report Number: Research and Policy Brief
  Date: 2006
  Topic: Health insurance and the uninsured
  Multiple studies have demonstrated that rural residents, particularly those living far from urban areas, have high uninsured rates. However, even those with private health insurance coverage can be at risk of having high out-of-pocket health care costs. Understanding the degree to which rural residents are "underinsured" has important implications for rural health policy and practice.
• Smallest Rural Hospitals Treat Mental Health Emergencies
  Author(s): David Hartley, Stephenie Loux
  Report Number: Research and Policy Brief
  Date: 2006
  Topics: Hospitals and clinics, Mental health
  Discusses the extent to which rural emergency rooms encounter and treat mental health patients.
• Uninsured Rural Families
  Author(s): Erica Ziller, Andrew F. Coburn, N. Anderson, Stephanie Loux
  Report Number: Working Paper No. 34
  Date: 2006
  Topic: Health insurance and the uninsured
  

2005

• Out-of-Pocket Health Care Spending and the Rural Underinsured
  Author(s): Erika Ziller, Andrew Coburn, Anush Yousefian
  Report Number: Working Paper No. 33
  Date: 12 / 2005
  Topic: Health insurance and the uninsured
  Reports the results of a study to identify whether and to what extent there are rural-urban differences in underinsured rates among the privately insured, and, where differences exist, to understand what characteristics of rural residents are related to their likelihood of being underinsured. Using the 2001 and 2001 Medical Expenditure Panel Survey (MEPS), the authors examined the annual out-of-pocket health care expenditures for U.S.residents under age 65 that were continuously insured by a private plan in either 2001 or 2002. Findings showed that, despite having private health insurance coverage, those who use medical services continue to pay for a substantial portion of their own health care costs, particularly those living in rural areas. The average rural non-adjacent individual paid for 39% of their care in 2001 or 2002, compared to 35% for rural adjacent and 32% for urban individuals. Additional findings showed that one out of eight non-adjacent residents is underinsured (12.4%), compared to 10% of rural adjacent and 7% of urban residents.
• Mental Health Encounters in Critical Access Hospital Emergency Rooms: A National Survey
  Author(s): David Hartley, Erika Ziller, Stephenie Loux, John Gale, David Lambert, Anush Yousefian
  Report Number: Working Paper No. 32
  Date: 09 / 2005
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
  Investigates the extent and types of cases that present with mental health problems in Critical Access Hospitals (CAHs) emergency rooms (ERs), as well as the resources available to ER staff for addressing such problems and what actually happens to such patients. Emergency department managers in a random sample of 422 CAHs in 44 states completed a telephone survey (response rate = 84.7%) responding to questions about prevalence of mental health problems in their ER and what options they had for responding to such problems. On average, CAHs had 99 emergency room visits per week. Of these visits, 9.4% were mental health related. CAH ERs play a significant role in providing mental health services to rural residents. Although nearly 20% of mental health encounters result in transfers to other facilities, over 40% of mental health problems are addressed on-site through treatment or referrals. Nearly half (43%) of CAH ER managers reported having no access to local mental health providers of any kind.
• Scope of Services Offered by Critical Access Hospitals: Results of the 2004 National CAH Survey
  Author(s): David Hartley, Stephenie Loux
  Report Number: Flex Monitoring Team Briefing Paper No. 5
  Date: 03 / 2005
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Three years of national survey data (2000, 2002, and 2004) were used to examine the scope of services offered by Critical Access Hospitals (CAHs). The authors investigated how the services offered by CAHs have changed, the role of network affiliations in these changes, and the reasons administrators gave for reported service expansions. Additionally, the authors looked at how services in CAHs have changed over time. Consistent with findings in previous surveys conducted by the Flex Team, conversion to CAH status has not led to downsizing of services. Most CAHs offer a core set of services including radiology, laboratory services, emergency rooms, swing beds, pharmacy, outpatient rehabilitation, outpatient surgery, and specialty clinics. While this core has not changed significantly over the period of three surveys, many CAHs have added or expanded services not dependent on inpatient capacity Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Rural Health Research in Progress in the Rural Health Research Centers Program, 9th Edition
  Date: 02 / 2005
  Topic: Health policy
  Annual monograph providing policymakers with a concise source of rural health services research currently underway in the Rural Health Research Centers funded by the Office of Rural Health Policy. Provides a context for legislation current and proposed that affects rural health services and populations. A summary report booklet is provided to the federal Office of Rural Health Policy prior to the full printing of the monograph. The summary booklet is also distributed to members of the Senate Rural Caucus and the House Rural Health Care Coalition.
• Comparing Patient Safety in Rural Hospitals by Bed Count
  Author(s): Stephenie L. Loux, Susan M. C. Payne, Astrid Knott
  Citation: Advances in Patient Safety: From Research to Implementation. (Vols. 1-4), (pp. 391-402). Rockville, MD: Agency for Healthcare Research and Quality.
  Date: 2005
  Topics: Hospitals and clinics, Quality
  Reports results of a study to determine how patient safety rates, offered services, and patient mix vary by bed count among rural hospitals. The authors found that small rural hospitals had rates of potential patient safety events that were significantly lower than those of large rural hospitals for three of the 19 patient safety indicators (PSIs). The types of services offered by rural hospitals varied significantly according to bed numbers, and the likelihood of an offered service increased as bed counts increased. The types of patients treated by rural hospitals, however, did not vary significantly by bed count. The results suggest that rural hospitals differ substantially by offered services and differ somewhat in PSI rates, relative to bed counts. But given the limited information on patient severity using administrative data, future research should look to develop more effective ways to account for patient severity when measuring patient safety rates among hospitals with varying bed counts.
• Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff
  Author(s): Keith J. Mueller, Andrew F. Coburn, A. Clinton MacKinney, Timothy D. McBride, Rebecca T. Slifkin, Mary K. Wakefield
  Citation: Journal of Rural Health, 21(3), 194-197
  Date: 2005
  Topics: Health policy, Legislation and regulation, Medicare, Pharmacy and prescription drugs
  The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in September 2004 to identify a set of researchable questions concerning the impact of the MMA on rural health care. This paper presents research questions in the following areas that congressional staff identified as having the highest priority: access to health plans and pharmacy services, beneficiary outreach and enrollment, technology capacity, provider payment policy, and demonstration projects.

2004

• Are Advanced Practice Nurses A Solution To Rural Mental Health Workforce Shortages?
  Author(s): David Hartley, Valerie Hart, Nancy Hanrahan, Stephenie Loux
  Report Number: Working Paper No. 31
  Date: 04 / 2004
  Topics: Mental health, Nurses, Workforce
  Summarizes the clinical skills and prescriptive authority of Advanced Practice Psychiatric Nurses (APPNs), and investigates current trends in their geographic distribution to determine what their future role may be in addressing rural mental health needs. Includes information on prescription authority and collaboration requirements for each state, as well as state distribution of APPNs.
• Rural Health Research in Progress in the Rural Health Research Centers Program, 8th Edition
  Date: 02 / 2004
  Topic: Health policy
  Annual monograph providing policymakers with a concise source of rural health services research currently underway in the Rural Health Research Centers funded by the Office of Rural Health Policy. Provides a context for legislation current and proposed that affects rural health services and populations. A summary report booklet is provided to the federal Office of Rural Health Policy prior to the full printing of the monograph. The summary booklet is also distributed to members of the Senate Rural Caucus and the House Rural Health Care Coalition.
• Comparative Performance Data for Critical Access Hospitals
  Author(s): George H. Pink, Rebecca T. Slifkin, Andrew F. Coburn, John A. Gale
  Citation: Journal of Rural Health, 20(4), 374-382
  Date: 2004
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Quality
  Discusses the potential use of comparative performance data for critical access hospitals (CPD-CAH) to facilitate performance and quality improvement. Covers potential benefits and drawbacks of CPD-CH and identifies issues in the development and implementation of CPD-CAH.

2003

• Health Insurance Coverage Of The Rural And Urban Near Elderly
  Author(s): Erika C. Ziller, Andrew F. Coburn
  Report Number: Working Paper No. 27
  Date: 10 / 2003
  Topics: Aging, Health insurance and the uninsured
  Reports the results of a study that used data from the 1996-1998 Medical Expenditure Panel Survey (MEPS) to address two principal research questions related to health insurance coverage for the rural near elderly. Findings indicate that the rural near elderly are both more likely to be uninsured and to be in fair or poor health, and when the near elderly become uninsured they may have a much more difficult time regaining health insurance than younger groups. This issue may be even more problematic in rural areas as the findings indicate that 14% of the rural near elderly are uninsured for the entire survey year, compared to 10% of the urban near elderly.
• Rural Health Research In Progress in the Rural Health Research Centers Program, 7th edition
  Date: 03 / 2003
  Topic: Health policy
  Annual monograph providing policymakers with a concise source of rural health services research currently underway in the Rural Health Research Centers funded by the Office of Rural Health Policy. Provides a context for legislation current and proposed that affects rural health services and populations. A summary report booklet is provided to the federal Office of Rural Health Policy prior to the full printing of the monograph. The summary booklet is also distributed to members of the Senate Rural Caucus and the House Rural Health Care Coalition.
• Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook
  Author(s): John A. Gale, Andrew F. Coburn
  Date: 01 / 2003
  Topics: Health services, Rural Health Clinics (RHCs)
  Reports on the results of a national survey of Rural Health Clinics (RHCs). Information was collected on a wide range of topics of concern to RHCs including: 1) the characteristics and operations of the clinics; 2) their location relative to the underservice problems and access needs of rural areas; 3) safety net functions of RHCs; 4) staffing, recruitment and financial issues; and 5) involvement in the training of health care professionals. Among the findings: most RHCs continue to serve rural, underserved communities; RHCs are filling a valuable safety net role by serving Medicaid, uninsured, and low-income patients and providing free and reduced cost care; recruitment and retention is a problem for RHCs, and some RHCs face continued financial challenges despite cost-based reimbursement. RHCs continue to be an important source of primary care and safety net services in rural communities. Legislative efforts to address concerns about the program have included the refinement of the shortage area criteria used by the RHC program (Balanced Budget Act of 1997) and the implementation of a Medicaid prospective payment system (Benefits Improvement and Protection Act of 2000). Additional research is needed to understand the impact of these changes on the RHCs and the residents of rural communities served by them.

2002

• Role of Community Mental Health Centers as Rural Safety Net Providers
  Author(s): David Hartley, Donna C. Bird, David Lambert, John Coffin
  Report Number: Working Paper No. 30
  Date: 05 / 2002
  Topics: Federally Qualified Health Centers (FQHCs), Mental health
  Investigates the extent to which those organizations formerly designated as community mental health centers (CMHCs) currently act as a rural mental health safety net, e.g., provide mental health services for free or at reduced charges to rural populations not covered by public or private insurance or grants. Findings: Based on three comparative case studies, CMHCs continue to believe that it is within their mission to act as a mental health safety net, but all three also acknowledged that their priority population is now SPMI (serious and persistent mental illness) adults and SED (seriously emotionally disturbed) children. Their ability to serve indigent clients who do not fall into these categories depends on their ability to cross-subsidize such services with funds designated for their priority populations. These providers were also able to fund some safety net services with grant funds made available through federal and regional programs, often targeted to outreach and prevention. In Minnesota and Oregon, county government and county funded social services also supplemented the safety net in meaningful ways. Lacking such county involvement, the Maine CMHC was forced to use waiting lists to manage the demand for free care. We conclude that county funding and grant writing are two ways that CMHCs have been able to plug the otherwise widening hole in the rural mental health safety net. Based on the findings, the report recommends an explicit discussion of the mental health safety net, both urban and rural, using the Institute of Medicine's report on America's Health Care Safety Net as a model. Also recommended are outreach programs to facilitate access to services for rural residents experiencing stress, depression and anxiety, and a shift from diagnosis-specific funding to the use of a family systems approach for those thus referred.
• State Licensure Laws and the Mental Health Professions: Implications for the Rural Mental Health Workforce
  Author(s): David Hartley, Erika C. Ziller, David Lambert, Stephenie L. Loux, Donna C. Bird
  Report Number: Working Paper No. 29
  Date: 05 / 2002
  Topics: Legislation and regulation, Mental health, Workforce
  Investigates whether and the extent to which licensure laws that determine the permissible scope of practice for each of these professions may affect the availability of mental health services, particularly in rural communities. Findings: Licensure laws authorize non-physician mental health providers to practice assessment, treatment planning, and individual and group counseling independently in most of the 40 states studied. Many states do not explicitly grant the authority to all of these professions for diagnosis or psychotherapy, but none explicitly deny it. Despite this finding, Medicare and some other payers do not directly reimburse Marriage and Family Therapists or Licensed Professional Counselors. Laws that require clinical supervision of newly trained practitioners to be performed exclusively by a member of the profession in a face-to face setting may make it difficult for a new graduate seeking rural practice to log the number of required hours within the specified time limit to qualify for independent practice. Some states' laws allow supervision that is not face-to-face, a rural-friendly policy. Also discussed are the nature and effects of guild behavior in the mental health professions. Based on the findings, report recommends that states simplify licensure and clarify clinical roles by combining regulatory functions for several professions into a single office or agency; that Medicare reconsider its position on reimbursing Marriage and Family Therapists or Licensed Professional Counselors; that professional competition over the right to practice and be reimbursed be addressed; and that supervision requirements be modified to allow new mental health professional graduates to address rural needs soon after graduation.
• Diabetes and the Rural Safety Net
  Author(s): David Hartley, Erika Ziller, Caroline Macdonald
  Report Number: Working Paper No. 28
  Date: 01 / 2002
  Topics: Chronic diseases and conditions, Health insurance and the uninsured
  Investigates the extent to which the rural safety net is able to meet the needs of people with diabetes. Finds that small rural communities have a relatively greater need for safety net services to diabetics than their urban counterparts. To provide the needed array of services, medications, and support, a coordinated, team approach to care is needed. Such an approach would include the following elements: insurance coverage would be consistent with the standards of care; team management and care coordination would be facilitated, and the informal safety net would be formalized.

2001

• Patterns of Health Insurance Coverage Among Rural and Urban Children
  Author(s): Andrew F. Coburn, Timothy McBride, Erika Ziller
  Report Number: Working Paper No. 26
  Date: 11 / 2001
  Topics: Children, Health insurance and the uninsured
  Assesses differences in the patterns of insurance coverage and uninsured spells among rural and urban children in 20 states. Also examines the implications of those differences for the design and implementation of public insurance programs. Among its findings: Although the average duration of new uninsured spells was shorter among rural than urban children, rural children were more likely to experience protracted spells of uninsurance. Rural children were also more likely than urban children to move between public and private coverage. These findings have important implications for designing insurance expansion programs and outreach strategies to effectively enroll and retain rural children.
• Addressing Mental Health Workforce Needs in Underserved Rural Areas: Accomplishments and Challenges
  Author(s): Donna C. Bird, Patricia Dempsey, David Hartley
  Report Number: Working Paper No. 23
  Date: 10 / 2001
  Topics: Mental health, Workforce
  Reviews efforts to address mental health workforce needs in underserved rural areas and addresses three questions: 1) How is health and mental health workforce adequacy currently measured? 2) How do unique characteristics of rural communities and the mental health service delivery system challenge current methods for determining workforce adequacy? 3) What role has the federal government played in addressing health and mental health workforce needs in underserved rural areas? Finds that current workforce adequacy measurements all focus on physicians and are limited by the lack of a commonly accepted way to obtain needed data and by widely varying estimates of adequate population-to-provider ratios. In addition, the pluralistic and minimally coordinated nature of the mental health services system makes it difficult to translate methods for estimating workforce adequacy from health to mental health. Finally, there are several federal efforts to address workforce needs that foster training, provide scholarships, fund demonstration programs, and allow foreign medical graduates to serve in underserved areas. Makes several recommendations pertaining to the collection of data, field-testing of estimation models, and increasing the supply of mental health service providers.
• Admission Severity and Mortality Rates Among Rural and Urban Nursing Facility Residents with Dementia (Research & Policy Brief)
  Author(s): Elise J. Bolda, Kimberly Mooney Murray
  Date: 09 / 2001
  Topics: Long term care, Mental health
  Assesses whether the potentially higher utilization of nursing facility services in rural communities can be attributed to differences in use patterns by older adults with dementia. Specifically, addresses the question of whether rural nursing facility residents with dementia are less impaired at the time of their admission to a nursing facility than urban residents with dementia.
• Medicaid Managed Behavioral Health Programs in Rural Areas (Research and Policy Brief)
  Author(s): David Lambert, John Gale, Donna Bird, David Hartley
  Date: 08 / 2001
  Topics: Medicaid and S-CHIP, Mental health
  Study of which states have implemented Medicaid managed behavioral health (MMBH) programs in rural areas. Describes these programs in terms of Medicaid populations served, program design, and implementation model. Describe the experience of programs regarding access to and coordination of services.
• Developing Affordable Non-medical Residential Care in Rural Communities: Barriers and Opportunities
  Author(s): Elise J. Bolda, John W. Seavey, Kimberly Mooney Murray, Stephanie Flanary
  Report Number: Working Paper No. 18
  Date: 05 / 2001
  Topic: Long term care
  Explores the challenges and opportunities for affordable non-medical residential care (NMRC) development in rural areas.
• Admission Severity and Mortality Rates Among Rural and Urban Nursing Facility Residents with Dementia
  Author(s): Elise J. Bolda, Kimberly Mooney Murray
  Report Number: Working Paper No. 25
  Date: 03 / 2001
  Topic: Long term care
  Assesses whether the potentially higher utilization of nursing facility services in rural communities can be attributed to differences in use patterns by older adults with dementia. Specifically, addresses the question of whether rural nursing facility residents with dementia are less impaired at the time of their admission to a nursing facility than urban residents with dementia.
• Financing and Payment Issues in Rural Long Term Care Integration (Brief)
  Report Number: Research and Policy Brief
  Date: 02 / 2001
  Topics: Health care financing, Long term care
  Reviews current research and experience and identifies key policy and program considerations for integrated acute and long term care financing in rural areas.
• Medicaid Managed Behavioral Health in Rural Areas
  Author(s): David Lambert, John Gale, Donna Bird, David Hartley
  Report Number: Working Paper No. 24
  Date: 01 / 2001
  Topics: Medicaid and S-CHIP, Mental health
  Study of which states have implemented Medicaid managed behavioral health (MMBH) programs in rural areas. Describes these programs in terms of Medicaid populations served, program design, and implementation model. Describe the experience of programs regarding access to and coordination of services.

2000

• Designing a Prescription Drug Benefit for Rural Medicare Beneficiaries: Principles, Criteria, and Assessment
  Author(s): Andrew F. Coburn, Erika C. Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Date: 08 / 2000
  Topics: Medicare, Medicare Part D, Pharmacy and prescription drugs
  The purpose of this paper is to offer a rural perspective on the current debate over the design and implementation of a Medicare prescription drug benefit. Background information on rural Medicare beneficiaries' need for, and access to, prescription drugs is provided, along with a set of rural-oriented principles for use in evaluating how different prescription drug proposals may meet the needs of rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
• Improving Prescription Drug Coverage for Rural Medicare Beneficiaries: Key Rural Considerations and Objectives for Legislative Proposals
  Author(s): Andrew F. Coburn, Erika Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Date: 06 / 2000
  Topics: Legislation and regulation, Pharmacy and prescription drugs
  This Policy Paper combines the work from current projects of the Maine Rural Health Research Center (MRHRC) and the Rural Health Panel of the Rural Policy Research Institute (RUPRI) to provide a statement of specific rural considerations and objectives for any proposal that would add a prescription drug benefit to the Medicare program. Our intent is to establish a framework for assessing the effects of proposals on rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
• Financing and Payment Issues in Rural Long Term Care Integration (Full Report)
  Author(s): Paul Saucier, Julie Fralich
  Report Number: Working Paper No. 21
  Date: 2000
  Topics: Health care financing, Long term care
  Reviews current research and experience and identifies key policy and program considerations for integrated acute and long term care financing in rural areas. Finds that full capitation of acute and long term care payments is an urban financial integration model that is often not applicable in rural areas. Many rural areas do not have adequate infrastructure to support full capitation models, nor are such models necessarily consistent with the common rural area goal of preserving and strengthening existing providers. Other incremental payment approaches that support some integration of services are more feasible for rural areas, including the creation of fee-for-service incentives, partial capitation, and other risk limitation strategies.