Victoria Freeman, DrPH, RN

North Carolina Rural Health Research and Policy Analysis Center

Phone: 919.966.6168
Email: victoria_freeman@unc.edu

University of North Carolina - Chapel Hill


Completed Projects - (7)

21st Century Rural Hospital: Outpatient Services and Access to Care
The rural hospital has changed dramatically with hospitals becoming increasingly outpatient-centered. This project is designed to inform policymakers about rural hospitals' provision of outpatient care, including publication of a Primer, detailing the variability in outpatient services provision by key characteristics that can be used to examine the potential impact of proposed policy changes on patients' ability to access different services.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health policy, Hospitals and clinics
Access to Health Care for Young Rural Medicaid Beneficiaries
This study examined access to health care among rural children ages 0-17 who are enrolled in some type of Medicaid managed care program, and will compare this access across types of programs and, within program type, to that of urban beneficiaries.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Children, Dental health, Health services, Medicaid and S-CHIP
Comprehensive Study of Swing Bed Use in Rural Hospitals
This project will comprehensively address questions about how swing beds are used by rural hospitals. Questions to be answered include whether decision about use are driven by patient need, community resources, hospital operational concerns or some combination of these factors; the cost implications of swing bed use in critical access hospitals to the Medicare program; and whether patients served in swing beds differ in meaningful ways from those in skilled nursing facilities.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
Factors Associated with Provision of Ambulance Services by Rural Hospitals
This two-part study will use existing national data to determine how many hospitals have regularly offered ambulance services as well as how many have recently acquired or discontinued such services. In-depth interviews with selected rural hospital administrators will explore the factors related to a hospital's decision regarding these important health care services.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topic: Emergency medical services (EMS)
Rural Emergency Department Preparedness for Pediatric Care
While many large cities have dedicated children's hospitals or facilities with pediatric emergency departments, many general hospitals do not have either the equipment necessary to provide optimal pediatric emergency care nor staff that is specifically trained in the care of pediatric emergencies. This project will use secondary data analysis and semi-structured interviews with emergency room directors in order to address how the availability of pediatric services, expertise and supplies in U.S. emergency departments differs between urban and rural facilities, and to determine which factors impede the availability of pediatric services, expertise, and supplies in rural emergency departments.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Children, Health services, Hospitals and clinics
Rural Emergency Medical Services: Workforce and Medical Direction
This two year study will examine the status of medical direction for rural EMS systems and the nature of the challenges and impediments to obtaining adequate medical direction in rural areas across the country. In addition, the study will address issues surrounding the recruitment and retention of paid and volunteer staff for rural EMS systems.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Emergency medical services (EMS), Workforce
Volunteerism in Rural EMS
Semi-structured telephone interviews will be used to examine issues facing rural EMS services that have converted or are considering converting from volunteer services to paid services. Respondents will be queried regarding their conversion or consideration of conversion and the effect on their ability to recruit and retain personnel, their relationship with other agencies such as fire departments and hospitals, and the overall availability of EMS services.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Emergency medical services (EMS), Healthcare financing, Workforce

Publications - (30)

  • The 21st Century Rural Hospital: A Chart Book
    Chartbook
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2015

    Hospitals have changed over recent decades. Hospital stays are shorter. Procedures once requiring hospitalization are now done in an outpatient setting. Hospitals have moved beyond providing mainly inpatient and emergency department care. They have become vertically integrated systems with “one-stop shopping” for all of one’s health care needs.

    The transformation of hospitals has also occurred in rural areas where the presence of a hospital with traditional inpatient and emergency department services may also ensure that other healthcare is available. Even with a cursory scan of rural hospital websites, one can see that rural hospitals offer a variety of services that range from traditional inpatient medical, surgical and obstetric care to advanced imaging, laboratory, and rehabilitation services. Outpatient primary and specialty care are available, and hospitals provide important health promotion and wellness services for the community. Hospitals vary, however, based on their resources and the needs of the populations they serve. As is often said about many things, “if you’ve seen one hospital, you’ve seen one hospital.”

    This Chart Book uses available data to present a broad profile of the 21st century rural hospital and includes such descriptors as: Where are they located? Whom do they serve? What traditional hospital services do they provide? How do they ensure outpatient services for their community? What other community benefits do they provide or enable for citizens in their area? How are they doing financially? How are they supported by federal programs?

    The pages of The 21st Century Rural Hospital: A Chart Book are each designed as a pull-out document and describe many aspects of today’s rural hospital. Each page includes charts comparing rural hospitals to each other and to urban hospitals across different dimensions such as levels of rurality, US Census region, and hospital size. Important data points are emphasized and an illustrative rural hospital is highlighted. Those who are unfamiliar with today’s rural hospital may be surprised by many data points shown here; others may use this document to research a particular data point.

  • Becoming an Emergency Medical Technician: Urban-Rural Differences in Motivation and Job Satisfaction
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2007
    This study uses cross-sectional data from the 2003 national Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) Project to explore urban-rural differences in why EMTs enter the field, what is important in their jobs, and whether they are satisfied with their profession.
  • Cesarean Section Patterns In Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2004
    Examines childbirth delivery patterns in rural hospitals and compares the cesarean section (c-section) rate in rural hospitals to that in urban hospitals. The c-section rate for rural hospitals was well above the 10-15% rate recommended by the World Health Organization, and was higher (but not statistically significant) in rural hospitals than in urban hospitals. A Findings Brief on this topic is also available.
  • Cesarean Section Rates in Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2005
    Findings Brief examining childbirth delivery patterns in rural hospitals and comparing the C-section rate in rural hospitals to that in urban hospitals using the Nationwide Inpatient Sample (NIS). Working Paper No. 80 on this topic is also available.
  • Challenges for Rural Emergency Medical Services: Medical Oversight
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2008
    This Findings Brief examines the challenges faced by local rural EMS agencies in obtaining a medical director and ensuring medical oversight for EMS personnel, and also describes how the challenges faced in rural areas differ from those in urban ones. The data are from a national survey of 1,425 local EMS directors that was conducted in 2006-2007.
  • The Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.
  • Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2014

    Examines health conditions of patients discharged from rural Prospective Payment System (PPS) hospitals and Critical Access Hospitals (CAHs) to swing beds and skilled nursing facilities (SNFs).

  • Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2011
    This analysis estimates the average net cost to Medicare of a SNF swing day by simulating the elimination of all Medicare SNF swing bed days in CAHs in 2009.
  • Exploring the Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.
  • Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2014

    Combines the recently released data on plan selection in the Federally Facilitated Marketplaces with estimates of the population likely to qualify for the marketplace (i.e. “eligibles”) to calculate the percent of potential eligible individuals who chose a health insurance plan (the “uptake rate”). Contains a heat map that shows variation in uptake rates across the country.

  • Implications for Beneficiary Travel Time if Financially-Vulnerable Critical Access Hospitals Close
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Reports that changes to Critical Access Hospitals (CAHs) reimbursement may spur some CAHs to close, with the most financially vulnerable more likely to close. The average resident of these communities would experience an 80% increase in distance to the nearest hospital if the CAH were to close. This analysis considers the communities served by the 93 CAHs with the lowest profitability and therefore most likely to close due to a change in Medicare reimbursement.
  • Intensive Care In Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2005
    Describes what officials at Critical Access Hospitals (CAHs) mean when they report that they provide intensive care and the importance of these services to the hospital and the community it serves. Semi-structured interviews were conducted with Directors of Nursing at 63 CAHs in 27 states. Respondents described the physical structure of the intensive care area, equipment and staffing available for such care, types of patients who receive intensive care, transfer patterns, the role of intensive care in the decision to convert to CAH status, and the perceived value of this service to the community and hospital.
  • Intensive Care in Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 2007
    Describes the facilities, equipment, and staffing used by Critical Access Hospitals (CAHs) for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community.
  • Issues in Staffing Emergency Medical Services: A National Survey of Local Rural and Urban EMS Directors
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2008
    This report explores rural-urban differences in medical oversight and the recruitment and retention of emergency medical technicians (EMTs)and paramedics as reported by a survey of 1,425 local EMS directors.
  • Medicare Beneficiaries' Access to Pharmacy Services in Small Rural Towns: Implications of Contracting Patterns of Sole Community Pharmacies with Part D Plans
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2009
    Describes the contracting patterns of sole rural community pharmacies to assess the extent to which each pharmacy contracts with the most commonly used PDPs available in their state.
  • Pediatric Care in Rural Hospital Emergency Departments (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2010
    Analyzes data from the Emergency Pediatric Services and Equipment Supplement (EPSES) to the National Hospital Ambulatory Medicare Care Survey to compare rural and urban hospitals' responses on various dimensions of pediatric Emergency Department care.
  • Pediatric Care in Rural Hospital Emergency Departments (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2010
    Analyzes data from the Emergency Pediatric Services and Equipment Supplement(EPSES) to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Rural and urban hospitals' responses were compared on various dimensions of pediatric ED care. We also surveyed 65 ED directors at rural hospitals in a separate process to explore rural pediatric ED care in more detail and to obtain the opinion of rural ED administrators regarding ways to assure quality emergency care for children.
  • Reducing Mortality from Motor Vehicle Crashes for Children 0 through 14 Years of Age: Success in New York and North Dakota
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2004
    Reviews effective interventions to reduce motor vehicle crash mortality among children. Explores what is happening in New York and North Dakota that contributes to their success in being among the best performing states in regard to this measure of child health.
  • Rural and Urban Parents Report on Access to Health Care for their Children with Medicaid Managed Care
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2005
    There has been little previous research on rural beneficiaries' perspectives on access to care under Medicaid managed care. The study reported here considers the perspective of the rural beneficiary in four states in order to broaden understanding of whether Medicaid managed care programs provide acceptable access to healthcare services. The study examines access to healthcare among rural children ages 0-17 who are enrolled in either fully capitated (New Mexico and Washington) or primary care case management (PCCM) Medicaid managed care plans (North Carolina and North Dakota), and compares this access to that of urban beneficiaries. Overall, this study finds that parents of children living in the rural areas who are enrolled in a Medicaid managed care program are almost always able to get the medical care they need. Rural children who are Medicaid enrollees have primary care providers, their parents know how to access care when needed after hours, and although rural children sometimes use the ER, they do not rely on that source of care more than urban parents do. Where barriers to medical care are reported, they are often consistent with those barriers reported for rural residents generally, and do not appear to be related to restrictions from managed care programs. Access to dental services remains a substantial problem, not just for children in rural areas, but for all Medicaid enrollees. 2004
  • Rural Hospital Support for Emergency Medical Services (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2010
    This study uses Medicare Hospital Cost Reports to identify rural hospitals, with and without Emergency Medical Services (EMS) units, to answer the following questions: what proportion of rural hospitals support or operate EMS units; has this changed in last five years; what are the characteristics of rural hospitals that support or operate EMS; what are the financial investments made by these hospitals in EMS; and what describes the communities in which these hospitals are located.
  • Rural Hospital Support for Emergency Medical Services (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2010
    This study uses Medicare Hospital Cost Reports to identify rural hospitals, with and without Emergency Medical Services (EMS) units, to answer the following questions: what proportion of rural hospitals support or operate EMS units; has this changed in last five years; what are the characteristics of rural hospitals that support or operate EMS; what are the financial investments made by these hospitals in EMS; and what describes the communities in which these hospitals are located.
  • Rural Volunteer EMS: Reports from the Field (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2010
    This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondent agencies were considered to be rural if they were located in a nonmetropolitan county or within a metropolitan county in an area with a Rural Urban Commuting Area (RUCA) code of four or higher. A semi-structured interview format encouraged respondents to speculate on the future viability of their local service, describe the challenges they face and what they need to ensure continuance. The descriptions presented represent the perceptions of those interviewed, but are also likely to resonate with other rural EMS administrators.
  • Rural Volunteer EMS: Reports from the Field (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2010
    This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondent agencies were considered to be rural if they were located in a nonmetropolitan county or within a metropolitan county in an area with a Rural Urban Commuting Area (RUCA) code of four or higher. A semi-structured interview format encouraged respondents to speculate on the future viability of their local service, describe the challenges they face and what they need to ensure continuance. The descriptions presented represent the perceptions of those interviewed, but are also likely to resonate with other rural EMS administrators.
  • Rural-Urban Differences in Characteristics of Local EMS Agencies
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2008
    This Findings Brief describes the general characteristics of local rural EMS agencies and important ways that they differ from the characteristics of agencies located in urban areas. The data are from a national survey of 1,425 local EMS directors that was conducted in 2006-2007.
  • Rural/Urban Differences in Inpatient Related Costs and Use among Medicare Beneficiaries
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Reports that Medicare beneficiaries who are admitted to rural hospitals tend to have lower outpatient costs than Medicare beneficiaries admitted to urban hospitals. These differences are due to multiple factors, some of which were adjusted in the comparison. The analysis suggests that consideration of the total cost of an acute episode of care might be considered, not just the cost of the acute inpatient stay.
  • Safety Net Clinics Serving the Elderly in Rural Areas: Rural Health Clinic Patients Compared to Federally Qualified Health Center Patients
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2014

    Uses data extracted from 2009 Medicare outpatient provider claims to look at the location of clinics, the number of beneficiaries served, and the number of and cost per claim for each type of rural safety net clinic. We further examined characteristics of Medicare beneficiaries comparing their age, the health problems for which they sought care, and the distance they travelled to obtain care. Because Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) are similar in mission but may be different in practice, understanding their respective Medicare patient profiles is important. This findings brief is the third and final in a series on RHCs which draws on a large, national dataset that includes claims data on the approximately 90% of RHCs that billed Medicare in 2009.

  • Sole Community Pharmacies and Part D Participation: Implications for Rural Residents (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2009
    This findings brief describes the contracting rates of sole rural community pharmacies in 16 states to assess the extent to which each pharmacy contracts with the most commonly used PDPs available in their state.
  • Trends in Skilled Nursing Facility and Swing Bed Use in Rural Areas Following the Medicare Modernization Act of 2003 (Final Report)
    Rapid Response to Requests for Rural Data Analysis
    Date: 04/2011
    Provides descriptive evidence on current trends in the availability and use of swing beds and skilled nursing facility services in rural areas.
  • Trends in Skilled Nursing Facility and Swing Bed Use in Rural Areas Following the Medicare Modernization Act of 2003 (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2011
    This findings brief looks at if the the availability of post-acute skilled care stabilized, and how and where is it being provided today now that the reimbursement policy changes begun in the late 1990s have been fully implemented.
  • Why Use Swing Beds? Conversations with Hospital Administrators and Staff (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2012
    In this study we interview hospital administrators and staff about the use of swing beds. Topics include the role of swing beds in patient care, swing bed volume and financial considerations, swing beds in the context of all community post-acute skilled care and swing beds as a benefit for community residents.