David Hartley, PhD, MHA

Contact information for this researcher is no longer available, but you can still access their previous work.


Completed Projects - (16)

Adolescent Alcohol Use in Rural Areas: What Are the Issues?
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.
Research center: Maine Rural Health Research Center
Topic: Substance abuse
Chronic Illness and the Rural Informal Safety Net: The Case of Diabetes
Research center: Maine Rural Health Research Center
Topics: Chronic diseases and conditions, Health insurance and the uninsured
Database for Rural Health Research in Progress
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.
Research center: Maine Rural Health Research Center
Topic: Health policy
Effects of Scope of Service and Reimbursement on Access to Mental Health Services in Rural Areas
Research center: Maine Rural Health Research Center
Topics: Health services, Health services, Mental health
Health Reform-Rapid Response
This project will include several projects as requested by ORHP and DHHS as those agencies prepare for national health reform. Responses are primarily in the areas of health insurance and behavioral health.
Research center: Maine Rural Health Research Center
Topics: Health policy, Health services, Healthcare financing, Mental health
Implications of Mental Health Comorbidity and Rural Residence for Health Care Use Patterns of Individuals with Chronic Disease
This study will use the 2005-2010 panels of the Medical Expenditure Panel Survey (MEPS) to compare the prevalence of concurrent mental health and chronic illnesses across rural and urban populations and to describe relationships among comorbidity, residence, and health care use. Findings will inform public and private decisions on how best to allocate new resources available for mental health/primary care integration efforts.
Research center: Maine Rural Health Research Center
Topics: Chronic diseases and conditions, Mental health
Mental Health Encounters in Critical Access Hospital Emergency Rooms: A National Survey
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.
Research center: Maine Rural Health Research Center
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
Mental Health Services in Rural Jails
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.
Research center: Maine Rural Health Research Center
Topic: Mental health
National Study of Substance Abuse Prevalence and Treatment Services in Rural Areas
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.
Research center: Maine Rural Health Research Center
Topics: Health disparities, Health services, Rural statistics and demographics, Substance abuse
Patterns of Care for Rural and Urban Children with Mental Health Problems
This study will assess whether use of office-based care and psychotropic medicine by children differs between rural and urban areas, as well as the role of insurance coverage and availability of mental health providers on use of these services.
Research center: Maine Rural Health Research Center
Topics: Children, Health disparities, Mental health
Provision of Specialty Mental Health Services by Rural Health Clinics
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.
Research center: Maine Rural Health Research Center
Topics: Health services, Mental health, Rural Health Clinics (RHCs), Substance abuse
Role of Advanced Practice Registered Nurses in Addressing Mental Health Workforce Shortages
Research center: Maine Rural Health Research Center
Topics: Mental health, Nurses, Workforce
Role of Community Mental Health Centers as Rural Safety Net Providers
Research center: Maine Rural Health Research Center
Topics: Federally Qualified Health Centers (FQHCs), Mental health
Role of Inpatient Psychiatric Units in Small Rural Hospitals and Rural Mental Health Systems
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.
Research center: Maine Rural Health Research Center
Topics: Health services, Hospitals and clinics, Mental health
Rural Maternal Smoking Behaviors
In this project, we will develop a chart book documenting the prevalence of mental health/substance abuse conditions and describing the utilization of mental health services in rural and urban settings.
Research center: Maine Rural Health Research Center
Topics: Health disparities, Mental health, Substance abuse
Year 2 of the Sentinel Cohort of Rural Health Clinics: Testing, Evaluating and Refining a Set of Rural Health Clinic Quality Measures
This project implements the set of core consensus quality measures identified during Year One of the Rural Health Clinic (RHC) Sentinel Cohort project among a group of approximately 130 RHCs in 13 states.
Research center: Maine Rural Health Research Center
Topics: Quality, Rural Health Clinics (RHCs)

Publications - (29)

  • Addressing Mental Health Workforce Needs in Underserved Rural Areas: Accomplishments and Challenges
    Maine Rural Health Research Center
    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.
  • Adolescent Alcohol Use: Do Risk and Protective Factors Explain Rural-Urban Differences? (Policy Brief)
    Maine Rural Health Research Center
    Date: 03/2012
    After controlling for a broad range of key risk and protective factors, it is clear that an unexplained rural effect persists with rural adolescents still exhibiting higher alcohol use than their urban counterparts
  • Adolescent Alcohol Use: Do Risk and Protective Factors Explain Rural-Urban Differences? (Working Paper)
    Maine Rural Health Research Center
    Date: 03/2012
    Rural adolescent alcohol use is a complex social problem. Using data from the 2008-2009 National Survey of Drug Use and Health, this study by the Maine Rural Health Research Center examines alcohol use among rural and urban adolescents between the ages of 12 and 17. After controlling for a broad range of key risk and protective factors, it is clear that an unexplained rural effect persists with rural adolescents still exhibiting higher alcohol use than their urban counterparts. Our findings suggest that rural adolescents who start drinking at an earlier age are more likely to engage in problem drinking behavior as they get older, leading to a need for interventions that target pre-teens and younger adolescents. Moreover, we found urban-rural differences in specific protective factors, which may be the most promising for evidence-based, rural-specific prevention strategies targeting parents, schools, and churches.
  • Adoption and Use of Electronic Health Records by Rural Health Clinics: Results of a National Survey
    Policy Brief
    Maine Rural Health Research Center
    Date: 09/2015

    This study reports the extent of EHR implementation and use in a randomly selected sample of 1,497 Rural Health Clinics (RHCs) surveyed in 2013. Results show that RHCs are approaching parity with other physician practices, with nearly 72 percent reporting EHR adoption and use, and 63 percent indicating use by 90 percent or more of their staff. Among RHCs without an EHR, almost 44 percent plan to implement one within the next 12 months. In general, respondents performed well on Stage 1 meaningful use measures related to clinical care and patient management but lagged on the exchange of clinical information, reporting quality measures, implementing clinical decision support rules, conducting formulary checks, transmitting lab orders, and generating patient registries. This study suggests that RHCs without an EHR have continuing technical assistance needs to support EHR adoption. RHCs with an EHR need support to fully utilize the capabilities of their systems and meet the continually evolving standards for meaningful use.

  • Are Advanced Practice Nurses A Solution To Rural Mental Health Workforce Shortages?
    Maine Rural Health Research Center
    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.
  • Are Rural Health Clinics Part of the Rural Safety Net? (Policy Brief)
    Maine Rural Health Research Center
    Date: 09/2010
    Key Findings: 86% of independent RHCs offer free care, sliding fee scales, or both; 97% were currently accepting new Medicaid/SCHIP patients; RHCs' patient mix has a higher proportion of Medicaid/SCHIP patients in counties not served by a federally funded Community Health Center (CHC). Lacking the grant funds and federal technical assistance provided to CHCs to build service capacity, few RHCs have had the resources to expand their scope of services. The Affordable Care Act has made it clear that partnering with CHCs is an option for RHCs that find themselves serving safety net populations. More study is needed laying out the details of such arrangements, the reimbursement and governance implications, and the relative advantages and disadvantages from the perspectives of the CHC, the RHC, the physician, and especially, the patient.
  • Diabetes and the Rural Safety Net
    Maine Rural Health Research Center
    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.
  • Encouraging Rural Health Clinics to Provide Mental Health Services
    Maine Rural Health Research Center
    Date: 05/2010
    This study examined changes in the delivery of mental health services by Rural Health Clinics (RHCs), their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services. Key Findings:
    • Approximately 6% of independent and 2% of provider-based RHCs offer mental health services.
    • 38% of study RHCs reported their mental health services were not profitable but continued to provide them in response to community and patient needs.
    • An important factor in the development of RHC mental health services is the presence of a local champion who spearheads the development effort.
  • Implications of Rurality and Psychiatric Status for Diabetic Preventive Care Use among Adults with Diabetes
    Policy Brief
    Maine Rural Health Research Center
    Date: 05/2014
    Examines patterns of diabetic preventive care use among adults with diabetes to determine whether these patterns vary according to respondents’ rural/urban residence or psychiatric status (i.e. the presence/absence of a mental health diagnosis).
  • Meaningful Use of the Electronic Health Records by Rural Health Clinics
    Maine Rural Health Research Center
    Date: 02/2014

    Identifies the rates of electronic health record (EHR) adoption among a national random sample of Rural Health Clinics (RHCs) and the extent to which RHCs that have adopted an EHR are likely to achieve Stage 1 meaningful use. Fifty-nine percent of RHCs report having an EHR and independent RHCs were more likely than hospital-based RHCs to have an EHR. Common barriers to EHR adoption by RCHs include acquisition and maintenance costs, lack of capital, and potential productivity or income loss during transition.

  • Medicaid Managed Behavioral Health in Rural Areas
    Maine Rural Health Research Center
    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)
    Maine Rural Health Research Center
    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
    Maine Rural Health Research Center
    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.
  • Mental Health Services in Rural Jails (Policy Brief)
    Maine Rural Health Research Center
    Date: 09/2009
    The prevalence of mental illness among prison and jail inmates has attracted increasing attention in both mental health and criminal justice circles.
  • Mental Health Services in Rural Jails (Working Paper)
    Maine Rural Health Research Center
    Date: 08/2010
    Using a qualitative approach, this study explored the role of rural jails in the mental health systems in rural communities, investigating how rural jails manage mental health and substance abuse problems among inmates, determining barriers to providing mental health services faced by rural jails, and identifying promising practices for service delivery. Rural jail administrators and mental health providers understood the need for mental health services for jail inmates but were constrained by inadequate community mental health resources, lack of coordination with community mental health providers, and infrastructure challenges including facilities, transportation, training, and legal processes. Promising practices include short-term hold policies, separation of inmates with mental health concerns, and regular communication among stakeholders.
  • Patterns of Care for Rural and Urban Children with Mental Health Problems
    Maine Rural Health Research Center
    Date: 06/2013
    Reports that rural children are significantly less likely to be diagnosed and treated for non-ADHD mental health problems than urban children and are less likely to receive mental health counseling.
  • Pilot Testing a Rural Health Clinic Quality Measurement Reporting System
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2016
    More than 4,000 Rural Health Clinics (RHCs) serve the primary care needs of rural communities. Unfortunately, the Rural Health Clinic Program is plagued by a lack of data participating clinics. This reports on the results with a focus on assessing the feasibility and utility of the reporting system and quality measures for the participating RHCs.
  • The Provision of Mental Health Services by Rural Health Clinics
    Maine Rural Health Research Center
    Date: 05/2010
    The number of Rural Health Clinics (RHCs) providing specialty mental health services remains limited. This study examined changes in the delivery of mental health services by RHCs, their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services. Approximately 6% of independent and 2% of provider-based RHCs offer mental health services by doctoral-level psychologists and/or clinical social workers. Models used to provide mental health services include contracted and/or employed clinicians housed in the same facility as primary care providers. A key element in the development of mental health services is the presence of an internal champion (typically clinicians or senior administrators) who identify the need for and undertake implementation of services, help overcome internal barriers, and direct resources to the development of services.
  • The Role of Community Mental Health Centers as Rural Safety Net Providers
    Maine Rural Health Research Center
    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 Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2015

    The patient-centered medical home (PCMH) model both reaffirms traditional primary care values such as continuity of care, connection with an identified personal clinician, provision of same day- and after-hours access and also prepares providers to succeed in the evolving healthcare system by focusing on accountability, continuous quality improvement, public reporting of quality data, data exchange, and patient satisfaction. However, little is known about the readiness of the over 4,000 Rural Health Clinics (RHCs) to meet the PCMH Recognition standards established by the National Council for Quality Assurance (NCQA). This policy brief reports findings from a survey of RHCs that examined their capacity to meet the NCQA PCMH requirements, and discusses the implications of the findings for efforts to support RHC capacity development.

    Key Findings:

    • Based on their performance on the “must pass” elements and related key factors, Rural Health Clinics (RHCs) are likely to have difficulties gaining National Center for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) Recognition.
    • RHCs perform best on standards related to recording demographic information and managing clinical activities, particularly for those using an electronic health record.
    • RHCs perform less well on improving access to and continuity of services, supporting patient self-management skills and shared decision-making, implementing continuous quality improvement systems, and building practice teams.
    • RHCs are likely to need substantial technical assistance targeting clinical and operational performance to gain NCQA PCMH Recognition.
  • Rural Inpatient Psychiatric Units Improve Access to Community-Based Mental Health Services, but Medicare Payment Policy a Barrier
    Maine Rural Health Research Center
    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.
  • Rural-Urban Differences in Work Patterns Among Adults With Depressive Symptoms
    Maine Rural Health Research Center
    Date: 03/2008
    This study addresses the issue of poor mental health among young to middle-career rural residents and how their employment may be affected. Using the National Longitudinal Survey of Youth (NLSY), a nationally representative survey of adults, the authors investigate how depressive symptoms affect employment patterns, and the extent to which such effects differ by rural and urban residence. Analysis of the data identified the rural sample as more likely to be married, have less education, are less likely to be black or Hispanic, and less likely to have health insurance than the urban sample. For both rural and urban subjects, individuals with depressive symptoms work less than those not depressed. Although the findings indicate no significant difference between depressed rural and urban residents in maintaining employment, questions remain about rural access to mental health services, such as employee assistance, productivity on the job, and the survival or coping strategies of rural workers with depressive symptoms.
  • Safety Net Activities of Independent Rural Health Clinics
    Maine Rural Health Research Center
    Date: 09/2010
    Rural Health Clinics (RHCs) are an important part of the rural health care infrastructure, providing a wide range of primary care services to the rural residents of 45 states. Since RHCs are located in underserved rural areas and serve vulnerable populations, many consider them safety net providers. In this paper we explore whether and to what extent independent RHCs are serving a safety net role, or have the capacity to serve that role.
  • Scope of Services Offered by Critical Access Hospitals: Results of the 2004 National CAH Survey
    Maine Rural Health Research Center
    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
    Maine Rural Health Research Center
    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
    Maine Rural Health Research Center
    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.
  • Telemental Health in Today's Rural Health System
    Maine Rural Health Research Center
    Date: 12/2013
    Describes the organizational setting, services provided, and staff used in 53 telemental rural health programs. Also outlines the opportunities and challenges for telemental health in the rural health system.
  • Understanding the Business Case for Telemental Health in Rural Communities
    Maine Rural Health Research Center
    Date: 07/2016
    This article describes the current landscape and characteristics of rural telemental health programs and then examines their business case.
  • Use of Critical Access Hospital Emergency Rooms by Patients With Mental Health Symptoms
    Maine Rural Health Research Center
    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.