John A. Gale, MS

Maine Rural Health Research Center

Phone: 207.228.8246
Fax: 207.780.4417
E-mail: jgale@usm.maine.edu

Maine Rural Health Research Center
University of Southern Maine
PO Box 9300
Portland, ME 04104

Current Projects

Adolescent Alcohol Use in Rural Areas: What Are the Issues?
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Substance abuse
This study will use the National Survey on Drug Use and Health (NSDUH) to examine the effect of developmental, individual, and environmental factors on adolescent alcohol use across the urban-rural continuum.

Availability, Characteristics, and Role of Detoxification Services in Rural Areas
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Substance abuse
This project will produce a comprehensive description of the distribution and characteristics of detoxification (detox) services across rural areas including a discussion of access issues, the role of detox services within local systems of care, barriers to the delivery of detox services by rural providers, and policy and regulatory incentives needed to encourage the development of rural detox services. Products will include a working paper and related journal articles addressing these topics.

Measuring the Community Benefits and Impact of Critical Access Hospitals
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
This project will develop, test, and implement a set of community benefits and impact indicators for Critical Access Hospitals (CAHs). These indicators will assist CAHs, policymakers, and rural stakeholders to understand the impact of CAHs on their communities and local health care delivery systems.

Provision of Specialty Mental Health Services by Rural Health Clinics
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Mental health, Rural Health Clinics (RHCs), Substance abuse
This project will document the extent to which Rural Health Clinics (RHCs) are employing mental health staff nationally, understand why more RHCs are not employing specialty mental health staff, and analyze the barriers to and opportunities for the delivery of mental health services by RHCs. The results will identify opportunities and interventions to encourage RHCs to offer this important service.

The Safety Net Role of Independent Rural Health Clinics
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs)
This national study will investigate and describe the safety net role of independent Rural Health Clinics (RHC). It will further examine the market effect of Federally Qualified Health Centers (FQHC) on the safety net role of independent RHCs at the county level.

Completed Projects

Analysis of 2004-2005 State Flex Grant Plans
Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Networking and collaboration, Quality
This project will analyze state Flex grant applications and related budget and work plan revisions focusing on state activities in the core Flex program areas of networks, quality improvement, and EMS.

Development of State Flex Program Logic Models and Related Toolkit
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program

Evaluation of New Hampshire's Rural Hospital Flexibility Program, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Bureau of Rural Health & Primary Care, Office of Community & Public Health, NH DHHS
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
Evaluation of the New Hampshire Rural Hospital Flexibility Program (NH Flex Program) will focus on the experience of the hospitals that have converted to Critical Access Hospital (CAH) status, the assistance provided to the remaining hospitals that are eligible for conversion, and the satisfaction of the staff of the hospitals and related community organizations with the support and assistance provided to them.

National Study of Rural Health Clinics, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Rural Health Clinics (RHCs)

National Study of Substance Abuse Prevalence and Treatment Services in Rural Areas
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
This project will research the prevalence of the abuse of legal and illegal substances across rural populations and geographic areas, including the extent to which rural individuals are receiving treatment for their substance abuse and barriers to the receipt of treatment.

Special Study of EMS Issues
Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Networking and collaboration
This study will focus on state, community, and hospital level initiatives designed to build the infrastructure to support EMS service capacity and encourage the integration of these services into the rural healthcare infrastructure in the areas of quality improvement, financing, staffing, medical control, and networking and integration.

Using Program Logic Models to Monitor the Performance of State Flex Programs
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
This project will use a program logic model approach to track state program activities and develop tools that allow states to systematically monitor and manage their accomplishments in the context of Flex Program goals.

Publications

• Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook
  Author(s): John A. Gale, Andrew F. Coburn
  Research center: Maine Rural Health Research Center
  Topics: Health services, Rural Health Clinics (RHCs)
  Date: 01 / 2003
  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.
• Community Impact of Critical Access Hospitals
  Author(s): John A. Gale, Andrew F. Coburn, Victoria Freeman, Walter R. Gregg, Rebecca Slifkin
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Policy Brief No. 2
  Date: 02 / 2007
  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.
• Comparative Performance Data for Critical Access Hospitals
  Author(s): George H. Pink, Rebecca T. Slifkin, Andrew F. Coburn, John A. Gale
  Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Quality
  Citation: Journal of Rural Health, 20(4), 374-382
  Date: 2004
  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.
• Creating Program Logic Models: A Toolkit for State Flex Programs
  Author(s): John Gale, Stephenie Loux, Andrew Coburn
  Research center: Maine Rural Health Research Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Date: 04 / 2006
  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.
• Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum
  Author(s): Jennifer D. Lenardson, John A. Gale
  Research center: Maine Rural Health Research Center
  Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
  Report Number: Working Paper No. 35
  Date: 10 / 2007
  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.
• Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum (Research & Policy Brief No. 35B)
  Author(s): Jennifer D. Lenardson, John A. Gale
  Research center: Maine Rural Health Research Center
  Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
  Date: 02 / 2008
  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.
• 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
  Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS)
  Report Number: Flex Monitoring Team Briefing Paper No. 8
  Date: 02 / 2006
  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.
• Exploring the Community Impact of Critical Access Hospitals
  Author(s): John Gale, Andrew Coburn, Walt Gregg, Rebecca Slifkin, Victoria Freeman
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Report Number: Flex Monitoring Team Briefing Paper No. 14
  Date: 01 / 2007
  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.
• Integrating Primary Care and Mental Health: Current Practices in Rural Community Health Centers
  Author(s): David Lambert, John Gale
  Research center: Maine Rural Health Research Center
  Topics: Federally Qualified Health Centers (FQHCs), Mental health
  Citation: Kansas City, MO: National Rural Health Association
  Date: 10 / 2006
  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.
• Medicaid Managed Behavioral Health in Rural Areas
  Author(s): David Lambert, John Gale, Donna Bird, David Hartley
  Research center: Maine Rural Health Research Center
  Topics: Medicaid and S-CHIP, Mental health
  Report Number: Working Paper No. 24
  Date: 01 / 2001
  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.
• Medicaid Managed Behavioral Health Programs in Rural Areas (Research and Policy Brief)
  Author(s): David Lambert, John Gale, Donna Bird, David Hartley
  Research center: Maine Rural Health Research Center
  Topics: Medicaid and S-CHIP, Mental health
  Date: 08 / 2001
  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.
• Mental Health Care in Rural Communities: the Once and Future Role of Primary Care
  Author(s): John A.Gale, David Lambert,
  Research center: Maine Rural Health Research Center
  Topics: Health services, Mental health
  Citation: North Carolina Medical Journal, 67(1), 66-70
  Date: 2006
  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.
• 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
  Research center: Maine Rural Health Research Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
  Report Number: Working Paper No. 32
  Date: 09 / 2005
  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.
• Quality and Performance Improvement Grant Activities Under the Flex Program
  Author(s): Jennifer Lenardson, John Gale
  Research center: Maine Rural Health Research Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Quality
  Report Number: Flex Monitoring Team Briefing Paper No. 12
  Date: 08 / 2006
  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.
• Review of State Flex Program Plans, 2004-2005
  Author(s): Stephenie Loux, John Gale, Anush Yousefian, Andrew Coburn, Walter Gregg
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Flex Monitoring Team Briefing Paper No. 10
  Date: 03 / 2006
  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.
• Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices
  Author(s): Donald Sawyer, John Gale, David Lambert
  Research center: Maine Rural Health Research Center
  Topics: Frontier health, Mental health, Substance abuse, Telehealth
  Citation: Waite Park, MN: National Association of Rural Mental Health
  Date: 2006
  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.
• 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
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Flex Monitoring Team Policy Brief No. 3
  Date: 04 / 2007
  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.
• 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
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Flex Monitoring Team Briefing Paper No. 15
  Date: 10 / 2007
  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.
• 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
  Research center: Maine Rural Health Research Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
  Citation: Journal of Rural Health, 23(2), 108-115
  Date: 2007
  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.