David Hartley, PhD, MHA

Director, Maine Rural Health Research Center

Phone: 207.780.4513
Fax: 207.780.4417
E-mail: davidh@usm.maine.edu

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

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.

Mental Health Services in Rural Jails
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Mental health
This project will investigate how rural jails manage the mental health and substance abuse problems of their inmates. Through analysis of the National Survey of Jails and semi-structured interviews with state-level and county-level/local officials, barriers to providing such services will be assessed and promising practices will be documented.

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.

Completed Projects

Active Living for Rural Youth, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Robert Wood Johnson Foundation (RWJF)
Topics: Children, Health promotion and disease prevention
This project will investigate how and where rural youth in Maine are physically active, and will help to define the built and natural environmental factors that support and limit physical activity of youth in rural communities. We will assess whether current theories that model the determinants of physical activity are appropriate for rural communities and rural residents.

Chronic Illness and the Rural Informal Safety Net: The Case of Diabetes, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Chronic diseases and conditions, Health insurance and the uninsured

Database for Rural Health Research in Progress, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Health policy
This searchable database of current rural health services research and policy analysis includes all ORHP-funded studies as well as research funded by other federal agencies, major private foundations and other sources.

Effects of Local Hospital Transitions on Rural Economic Development, Lead researcher
Research center: Maine Rural Health Research Center
Funder: U.S. Department of Agriculture (USDA)
Topics: Economic development, Hospitals and clinics

Effects of Scope of Service and Reimbursement on Access to Mental Health Services in Rural Areas, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Health services, Mental health

Mental Health Encounters in Critical Access Hospital Emergency Rooms: A National Survey, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
This project will survey Emergency Room (ER) managers in a nationally representative sample of Critical Access Hospitals (CAHs) to determine the proportion of ER encounters involving mental health pathology, types of mental health problems most commonly seen in these encounters, and resources available to CAHs to address the problems encountered.

National Study of Substance Abuse Prevalence and Treatment Services in Rural Areas, Lead researcher
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.

Role of Advanced Practice Registered Nurses in Addressing Mental Health Workforce Shortages, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Mental health, Nurses, Workforce

Role of Community Mental Health Centers as Rural Safety Net Providers, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Federally Qualified Health Centers (FQHCs), Mental health

Role of Inpatient Psychiatric Units in Small Rural Hospitals and Rural Mental Health Systems, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Hospitals and clinics, Mental health
This is a descriptive, exploratory study which will investigate the role of the small rural hospital IPU from the perspectives of both the rural hospital, in terms of scope of services and revenue enhancement, and the regional mental health system, meeting the needs of outpatient mental health and primary care providers, law enforcement, and human services.

Publications

• Addressing Mental Health Workforce Needs in Underserved Rural Areas: Accomplishments and Challenges
  Author(s): Donna C. Bird, Patricia Dempsey, David Hartley
  Research center: Maine Rural Health Research Center
  Topics: Mental health, Workforce
  Report Number: Working Paper No. 23
  Date: 10 / 2001
  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.
• Are Advanced Practice Nurses A Solution To Rural Mental Health Workforce Shortages?
  Author(s): David Hartley, Valerie Hart, Nancy Hanrahan, Stephenie Loux
  Research center: Maine Rural Health Research Center
  Topics: Mental health, Nurses, Workforce
  Report Number: Working Paper No. 31
  Date: 04 / 2004
  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.
• Diabetes and the Rural Safety Net
  Author(s): David Hartley, Erika Ziller, Caroline Macdonald
  Research center: Maine Rural Health Research Center
  Topics: Chronic diseases and conditions, Health insurance and the uninsured
  Report Number: Working Paper No. 28
  Date: 01 / 2002
  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.
• 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 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.
• Role of Community Mental Health Centers as Rural Safety Net Providers
  Author(s): David Hartley, Donna C. Bird, David Lambert, John Coffin
  Research center: Maine Rural Health Research Center
  Topics: Federally Qualified Health Centers (FQHCs), Mental health
  Report Number: Working Paper No. 30
  Date: 05 / 2002
  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.
• 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
  Research center: Maine Rural Health Research Center
  Topics: Health services, Hospitals and clinics, Mental health
  Date: 08 / 2007
  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.
• Scope of Services Offered by Critical Access Hospitals: Results of the 2004 National CAH Survey
  Author(s): David Hartley, Stephenie Loux
  Research center: Maine Rural Health Research Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Report Number: Flex Monitoring Team Briefing Paper No. 5
  Date: 03 / 2005
  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.
• Smallest Rural Hospitals Treat Mental Health Emergencies
  Author(s): David Hartley, Stephenie Loux
  Research center: Maine Rural Health Research Center
  Topics: Hospitals and clinics, Mental health
  Report Number: Research and Policy Brief
  Date: 2006
  Discusses the extent to which rural emergency rooms encounter and treat mental health patients.
• 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
  Research center: Maine Rural Health Research Center
  Topics: Legislation and regulation, Mental health, Workforce
  Report Number: Working Paper No. 29
  Date: 05 / 2002
  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.
• 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.