Index
A
Access
to capital for rural hospitals, 137–138
to health information, enabling, 151
Accidents, 41
Accreditation programs, 72–73
Acute myocardial infarction (AMI) patients, 6
interventions for, 34
Administrative Simplification provisions, 167
Adoption of ICT in rural settings, 165–168
data standards for connectivity, 167
federal leadership, 166
finance, 168
information network components, 165–166
patient privacy laws, 166–167
Advanced Learning Institute, 52
Adverse event rates, 33
African American communities, 1, 17, 38, 91–92, 205, 211
Age distribution, in rural populations, 208–210
Agency for Healthcare Research and Quality (AHRQ), 4–5, 7, 12, 16–17, 21, 33, 55–56, 68, 71, 75, 84, 89, 120, 141, 164, 177
Health Information Technology Program, 16, 177
America, rural, defining, 1–3, 200–204
American Academy of Family Physicians (AAFP), 161, 174
American Health Quality Association, 67
American Hospital Association (AHA), 65, 89, 122, 229
American Osteopathic Association, 73
Amish settlements, 1
Applicants from rural areas, attracting qualified, 10, 112
Area Health Education Centers, 8, 88, 110
Asian Americans, 91–92
Assessment of availability and quality of mental health and substance abuse services, in rural areas, 12–13, 142
Assistance, needed by rural communities, 6
Association of American Medical Colleges, 122
Attracting rural students to health careers, 91–92
Availability, of parks and recreational facilities, 45
Availability of mental health and substance abuse services in rural areas, 12–13, 142
B
Balanced Budget Act of 1997, 130, 133
Beale, Calvin, 194
Behavioral Risk Factors Surveillance System surveys, 131
Behaviors. See Health behaviors and health threats in rural communities;
Social behaviors
Benefits Improvement and Protection Act of 2000, 130–131, 134
“Bottom-up” approach to health system reform, 5, 177
Bridges to Excellence program, 121
Broadband networks, 14
expanding federal efforts to extend into rural areas, 15, 172
Burdick Program. See Quentin Burdick Rural Program for Interdisciplinary Training
Bureau of Economic Analysis, 212
Bureau of Health Professions, 9, 111
Bureau of Indian Affairs, 9, 111
Bureau of Primary Health Care, 124, 140, 238
Bureau of the Census, 17, 200–201
Bush, George W., 159
C
California HealthCare Foundation, 121
Capital support, for rural health care institutions, 27
Cardiac care link, in Bridges to Excellence, 121
Caucasian Americans, 91
Center for Tracking Health System Change, 129
Centers for Disease Control and Prevention (CDC), 4, 101
Health Alert Networks, 159
Centers for Medicare and Medicaid Services (CMS), 7, 11, 16, 66– 72, 75, 104, 121n, 122, 136, 141, 174, 225
Centers of Excellence program, 8, 110
Certification programs, 72–73
Challenges facing rural providers, 123– 124
Changes
fundamental, in existing payment programs for physicians, 95
in the health care system, 12, 109
in rural populations, 204–207
Children’s Health Insurance Program, provider payments under, 12, 141
Choices, zero-sum, 43
Chronic disease management, 20, 72, 152–153
role of residents in, 107
Clinical knowledge and associated tools, 63
Coburn, Andrew, 194
Cochrane Collaboratives, 84
Code classifications, for the rural-urban continuum, 206
Collaboration
in improving population health and personal health care, 51–52
propensity toward, 20
Committee on the Future of Rural Health Care, 2, 22, 25, 89, 193–199
Committee on the Quality of Health Care in America, 159
Communications technologies in information networks, 166
Communities
hub role in standardized performance measures, 64
with nonfederal physician specialty services, 223
Community Access Program, 37
Community-based efforts, 20
toward a comprehensive health system, 5
Community-based technical assistance, with measuring and improving personal and population health care programs in rural areas, 7, 75
Community-centeredness, of improving population health and personal health care, 45–46
Community Facilities Program, 138
Community health centers, 125–126, 225, 237
regional conferences for, 7
Community health systems, 61
Community ICT applications, 151–153
communicating with the health system, 151–152
enabling access to health information, 151
managing chronic conditions, 152–153
Community level, personal and population health needs at, 3
Community resources
culture and society, 107–108
education system, 107
health system, 107
options for mobilizing, 106–109
Community Tracking Study Physician Survey, 129
Community-wide measurement and monitoring systems, 64–65
Commuting, to jobs in urban areas, 1
Comprehensive health system
community-based efforts toward, 5
demonstrations towards reform of, 5, 54–56
Comprehensive quality improvement program
clinical knowledge and associated tools, 63
key components of, 61–66
knowledge of the science of quality and safety improvement, 61–62
performance measurement and data feedback capabilities, 65
quality improvement processes and resources, 65–66
standardized performance measures, 63–65
Computerized decision support, 60
Congress, 20
Connecting for Health initiative, 159
Consistency, of regulatory and payment policies, 172–173
Consolidated Health Informatics (CHI) initiative, 167
Continuing education, 106
requirements in medical education, 89
Core competencies for health professionals, 2, 8, 81–87, 101
applying quality improvement, 8, 85–87
employing evidence-based practice, 8, 84–85
formal education programs for public health professionals, 101
providing patient-centered care, 8, 81–82
reforms to improve quality in, 81–87
working in interdisciplinary teams, 8, 83–84
Core health services
access to, 2
emergency medical services, 3
hospital care, 3
long-term care, 3
mental health and substance abuse services, 3
oral health care, 3
primary care in the community, 3
public health services, 3
Coronary angioplasty procedures, 35
Cost-based payment, 20
Cost-effectiveness, of current patterns of health care, 43
Costs reimbursed by health insurance, 25
Critical access hospitals (CAHs), 21, 123, 126, 230
locations of, 231
regional conferences for, 7
Cross-training
of physicians, 100
Crossing the Quality Chasm: A New Health System for the 21st Century, ix–xi, 2, 23, 30, 33
Cultural competency, of health care professionals, 108
Culture and society, as community resources, 20, 107–108
Current status
of funding for mental health and substance abuse services in rural areas, 13, 142
of health care, cost-effectiveness of, 43
of ICT in health care, 159–165
of quality improvement efforts in rural areas, 66–73
D
Data exchange
establishing secure platforms for, 27
expense of, 14
Data feedback capabilities, 65
Data repositories
in information networks, 166
in measuring and improving personal and population health care programs in rural areas, 7, 75
Data standards
for connectivity in adopting ICT in rural settings, 167
in information networks, 166
computerized, 60
Delivery systems. See Rural health care delivery systems
Demonstrations for comprehensive health system reform, 11
funded by the Department of Health and Human Services, 5, 54–56
Density. See Population density
Dental health training programs, 98–99
recommendations for strengthening, 10, 111–112
Department of Agriculture (USDA)
Community Facilities Program, 138
Economic Research Service, 200
Rural Utilities Service, 170
Department of Commerce, 163, 170, 200
Department of Education, 9–10, 111, 113
National Science Education Standards, 91
Department of Health and Human Services (DHHS), 23, 54, 68, 74, 123, 133, 136, 166
comprehensive health system reform demonstrations funded by, 5, 54–56
meeting the needs of rural communities, 6
Public Health Functions Working Group, 242
Department of Housing and Urban Development (HUD), Hospital Mortgage Insurance Program, 138
Detmer, Don E., 194–195
Diabetes, education program aimed at preventing, 55
Diabetes care link, in Bridges to Excellence, 121
Diagnostic information, storage and retrieval of, 156
Dialysis Facility Compare, 69
DICOM standard, 165
Digital age, rural health care in, 147–190
Digital divide, in rural populations, 216–217
Disability-related conditions, 234–235
Disadvantaged people
loan repayment programs for students, 8
social support for, 25
Discipline-specific skills, for public health professionals, 101
Disparities, rural, 68
Distance consultations, and patient monitoring, 156–157
Distance learning programs, 89, 96
Diverse resource contexts, standardized performance measures in, 64
Doctors Office Quality Information Technology project, 174
Domestic preparedness, federal allocations to states for, 228
E
Economic Research Service (ERS), 17, 200–201, 208
Education system
as a community resource, 107
in rural populations, 213–216
Educational attainment
by race, 215
in rural populations, 20
Effectiveness
of improving population health and personal health care, 43–44
of quality of care in rural communities, 34–35
Efficiency
of improving population health and personal health care, 47, 49
of quality of care in rural communities, 36–37
Electronic health records (EHRs), 13, 60–63, 149, 160–162
assisting rural providers in converting to, 15–16, 27, 173–175
financial assistance for, 27, 173–175
investing in, 15
storing, 155
Emergency care professionals, formal education programs for, 97–98
Emergency medical services, 6, 157–158
federal allocations to states for domestic preparedness, 228
levels of training for emergency medical technicians, 226–227
in rural health care delivery, 98, 226–229
Emergency medical technicians (EMTs), 226–227
Emergency rooms, staffing, 227
Employment, in rural populations, 212–213
Environment
influence on the health of individuals and populations, 4
toxic exposure/risk, 43
Equity
defining, 47
in improving population health and personal health care, 47, 50–51
of physician payments, 12
in quality of care in rural communities, 37–38
Ethnicity, population growth rates in rural populations by, 210
European descendants, 1
Evaluation of current funding mental health and substance abuse services in rural areas, 13, 142
Evidence-based practice, health professionals employing, 2, 8, 84–85
Evidence-based Practice Center, 120
Exercise, physical, lack of in rural communities, 39
Experientially-based workforce training programs, expanding in rural areas, 8–9, 87, 89, 109–110
Experimentation, rapid-cycle, 5
F
Faculty, recruiting more from rural practice, 10, 112
Federal allocations to states, for domestic preparedness, 228
Federal Communications Commission, 171
Federal leadership, in adopting ICT in rural settings, 166
Federally-funded financial incentives, for residency training programs, 10, 112
Federation of American Hospitals, 122
Finance, 119–146
in adopting ICT in rural settings, 168
pay-for-performance, 120–126, 140–141
public, 27
recommendations regarding, 140–142
for rural health care institutions, ix, 27
See also Funding of rural health care
Financial assistance for EHRs, 27, 173–175
Financial resources, 11–13
recommendations for providing adequate and targeted, 11–13, 140–142
Financial stability of rural health care providers
Findings
regarding human resources, 9–10, 110–111
regarding information and communications technology, 15, 173
regarding personal and population health needs, 4–5, 54, 56
First-contact roles, standardized performance measures of, 64
First responders, 226
1st Annual Crossing the Quality Chasm Summit: A Focus on Communities, 23–24
Flex Program, 230
Flexibility, needed by rural communities, 6
Formal education programs for physicians, 93–96
making fundamental changes in existing payment programs, 95
making incremental changes in existing payment programs, 95
Formal education programs for public health professionals, 101–102
core skills, 101
discipline-specific skills, 101
function-specific skills, 101
subject-specific skills, 102
workplace basics, 102
Formal education programs for the rural health professions workforce, 92–102
for dentists, 98–99
for emergency care professionals, 97–98
for health administrators, 100–101
for mental and behavioral health care professionals, 99–100
for nurses, 96
for pharmacists, 99
for physician assistants, 96–97
Fostering Rapid Advances in Health Care: Learning from System Demonstrations, 5, 23–24, 40, 177–178
population change in, 207
Function-specific skills, for public health professionals, 101
Funding of rural health care, 126–139, 141–142
access to capital for rural hospitals, 137–138
funding rural emergency medical services, 134–135
Medicare and Medicaid payments to primary care physicians, 129–130
Medicare and Medicaid support for nursing homes and home health services, 132–134
Medicare and Medicaid support for rural health clinics and community health centers, 131
Medicare hospital payments, 127– 129
need for financial stability in, 139
public health expenditures, 135–137
rural resources for dental care, 131–132
Funding of rural mental health and substance abuse services, 139– 140, 142
G
Geisinger Health System, 152
General Accountability Office (GAO), 130, 136
Genetic predispositions, influence on the health of individuals and populations, 4
Genomics, 158
Geriatric Education Centers, 8, 110
Global Patient Index, 176
Graduate medical education payments, under Medicare, 112
Graduate medical education (GME) programs, 94–95
Grand rounds, 84
Grigsby, Jim, 195–196
H
Handicapped people, social support for, 25
Hartley, David, 196
Health, United States, 2001 with Urban and Rural Chartbook, 38
Health administrators, formal education programs for, 100–101
Health Alert Networks, 159
Health and health care in rural communities
an integrated approach to improving, 30–59
range of interventions available to improve, 4–5, 54
Health behaviors and health threats in rural communities, 3, 20, 38–39
lack of regular physical exercise, 3, 39
likelihood of smoking, 38–39
self-reported obesity among women, 39
Health care leaders, 41
Health care professionals
cultural and linguistic competency of, 108
data needed on, 9
finding qualified, 3
lifelong educational programs for, 17, 180
Health care settings in rural communities, 1
distance consultations and patient monitoring, 156–157
e-encounters, 154
emergency care, 157–158
ICT applications in, 153–158
knowledge and decision support, 154–156
remote language and cultural interpretation, 154
storage and retrieval of diagnostic and health information, 156
Health care systems
changes in, 12
communicating with, 151–152
as a community resource, 107
infrastructure for, 20
providing leadership training to rural communities engaged in redesigning, 5, 56
in the U.S., calling for fundamental reform, 2
Health Careers Opportunity Program, 8, 110
Health Disparities Collaboratives: Changing Practice, Changing Lives, 124
Health Education and Training Centers, 8, 110
Health information technology (HIT), 176–177
enabling access to, 151
storage and retrieval of, 156
Health Information Technology Program, 16, 177
Health insurance
costs reimbursed by, 25
in rural populations, 217–218
See also Uninsurance rates in rural areas
Health Insurance Portability and Accountability Act of 1996, 72, 166–167
Administrative Simplification provisions of, 167
Health literacy in rural populations, 107–108, 213–216
levels of, 10–11
measuring, 113
Health policy, rural, 20–22, 45
Health Professions Education: A Bridge to Quality, 8
Health-related Internet applications
ensuring that rural communities can access and use, 14–15, 170–172
transferring messages by telecommunications access networks, 15, 172
Health Resources and Services Administration (HRSA), 4–12, 21, 55, 71–74, 88, 110, 137, 142, 169, 174–175, 225
Area Health Education Centers, 88, 110
Centers of Excellence program, 8, 110
Office of Rural Health Policy, 74
recruitment programs from, 93, 103
Health Sciences and Technology Academy, 91
Health system reform, 45
“bottoms up” approach to, 5
Healthy Communities Access Program, 37
Healthy lifestyles, 25
Heterogeneity, of rural communities, 1, 20
High Plains Rural Health Network, 152
High-speed access to the Internet, 170–172
Hill-Burton Program, 138
Hispanic communities, 1, 17, 38, 91–92, 211
HIV infection, 36
Home Health Compare, 69
Home ICT applications, 151–153
communicating with the health system, 151–152
enabling access to health information, 151
managing chronic conditions, 152–153
Hospital care in rural health care delivery, 229–230
full-time hospital-based registered nurses in rural counties, 232
Hospital Compare, 69
Hospital Mortgage Insurance Program, 138
Hospitals in rural areas, 229
Medicare-dependent, 21
operating margins of, 12
sole community, 20–21
Hullett, Sandral, 196
Human resources, 3, 7–11, 78–118
enhancing the rural health professions workforce, 3, 89–106
formal education programs for, 92–102
fundamental reforms to improve quality, 80–89
options for mobilizing community resources, 80, 106–109
recommendations for strengthening, 8–11, 109–113
I
Immunization campaigns, 25
Improvements in population health and personal health care, 39–52
effectiveness of, 43–44
leadership and collaboration in, 51–52
patient- or community-centeredness of, 45–46
safety of, 41–43
In-house presentations, 84
In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce, 93
Income, in rural populations, 20, 212–213
Incremental changes, in existing payment programs for physicians, 95
Indian Health Service (IHS), 9, 93, 111, 174–175, 225
expanding programs offered by, 8
planning for converting all paper health records to electronic, 16, 175
Indiana Network for Patient Care, 175–176
Informatics, 158
health professionals utilizing, 87
Information and communications technology (ICT) in rural areas, 13–17, 61–62, 147–153, 158–160, 165
accelerating the adoption of, 165–168
collaborations and demonstrations in, 175–178
current status of, 159–165
electronic health records, 161–162
expanding developmental programs for, 16, 175–178
in health care settings, 153–158
at home and in the community, 151–153
Internet connections, 160–161
personal health records, 162–163
in population health, 158–159
recommendations for better utilizing, 14–17, 169–180
strengthening, 40
technical requirements, 164–165
telemedicine, 163–164
Information and communications technology (ICT) infrastructure, 2–3, 159–160
advances in, 79
EHRs, 160
information exchange networks, 160
investing in building, 3
national data standards, 160
PHRs, 160
Information network components, 165–166
in adopting ICT in rural settings, 165–166
appropriate regulatory oversight, 166
communications technologies, 166
data standards, 166
databases and medical knowledge sources, 166
“Information prescriptions,” 151
Injuries, 41
Inpatient margins, 127–129
Institute for Healthcare Improvement, 66, 89
Institute for Safe Medication Practices, 89
Institute of Medicine (IOM), xi, 2, 22–23, 25, 30–31, 37, 136, 162
Institute of Medicine’s Quality Chasm series, 22–24
Crossing the Quality Chasm: A New Health System for the 21st Century, ix–xi, 2, 23, 30, 33
Fostering Rapid Advances in Health Care: Learning from System Demonstrations, 5, 23–24, 40, 177–178
Priority Areas for National Action: Transforming Health Care Quality, 24
Insurance. See Uninsurance rates in rural areas
Integrated approach to improving health and health care in rural communities, 30–59
health behaviors and health threats in rural communities, 38–39
improving population health and personal health care, 39–52
quality of care in rural communities, 31–38
recommendations, 52
Interdisciplinary teams, health professionals working in, 8, 83–84
International medical graduates (IMGs), 103
Internet connections in health care, 84, 160–161
Internet penetration rates, 216–217
Interventions available to improve health and health care in rural America, range of, 4–5, 54
Investing in EHRs, 15
Iowa Health Professions Inventory, 102
Isolation, 3
J
J-1 waiver physicians, 103
Johnson Foundation. See Robert Wood Johnson Foundation
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 33, 73, 75, 121n, 173
K
Kaiser Commission on Medicaid and the Uninsured, 217
Knowledge support, 84, 154–156
web-based, 84
L
Leadership
in improving population health and personal health care, 51–52
needed within health care institutions, 51
school, 41
Leadership for Community Change Program, 5, 52, 56
Leadership training, providing to rural communities engaged in health system redesign, 5, 56
Letter Report on Key Functionalities of EHRs, 162
Levels of training for emergency medical technicians, 226–227
Lifelong educational programs, for health care professionals, 17, 180
Limitations, higher rates among rural populations, 3
Linguistic competency, of health care professionals, 108
Linking, in standardized performance measures, 64
Literacy. See Educational attainment;
Health literacy in rural populations
Loan repayment programs, for disadvantaged students, 8
Local area telecommunication access (LATA) networks, 14, 171
Local protocols, 63
Local public health agencies (LPHAs), 241
Long-term care, in rural health care delivery, 20, 230–234
M
MacKinney, A. Clinton, 196–197
Mansfield University, Master’s Program in Community Psychology, 104
Markle Foundation, Connecting for Health initiative, 159
Master’s Program in Community Psychology, 104
Mayo Clinic website, 151
Measurement systems, community-wide, 64–65
Measures, of pay-for-performance, 124–126
Medicaid, provider payments under, 12, 141
Medical Compare, 69
Medical health training programs, recommendations for strengthening, 10, 111–112
Medical knowledge sources, in information networks, 166
Medical resources, 20
Medicare, 15
graduate medical education payments under, 112
historical underpayment of rural health providers under, 12
hospital payments from, 127–129
payment from, 20
Prospective Payment System, 72, 126–127, 130–131, 133
Medicare Advantage Data, 69n
Medicare and Medicaid, 27
graduate medical education programs through, 94–95
payments to primary care physicians, 129–130
providing financial incentives to providers who invest in electronic health records, 16, 175
support for nursing homes and home health services, 132–134
support for rural health clinics and community health centers, 131
Medicare-dependent hospitals, 21
Medicare Flex program, 71
Medicare Health Plan Compare, 69
Medicare Modernization Act of 2003, 104, 119, 125, 128, 130, 134, 138–139
pay-for-performance program mandated in, 123
Medicare Personal Plan Finder, 69n
Medicare Prescription Drug Improvement and Modernization Act of 2003, 21
Medicare Rural Hospital Flexibility Program, 230
Medication errors, 33
Medigap Data, 69n
Medline Plus, 151
Mental and behavioral health care professionals, formal education programs for, 99–100
Mental disorders, defined, 234n
Mental health and substance abuse services, in rural health care delivery, 12, 83, 234–238
Mental Health Parity Act, 139
Mental illness, defined, 234n
Mentoring program, for rural health providers, 9
Metropolitan areas, population change in, 207
Monitoring systems, community-wide, 64–65
Moscovice, Ira, 197
Multiethnicity, 17
N
National Adult Literacy Survey, 215n
National Advisory Committee on Rural Health and Human Services (NACRHHS), 67, 178
National Center on Vital and Health Statistics, 167
National Committee for Quality Assurance, 75, 121n, 173
National Committee on Vital and Health Statistics, 159
National Coordinator. See Office of the National Coordinator for Health Information Technology
National Council for Healthcare Leadership (NCHL), 5, 52, 56
National data standards, 160
National Disparities Report, 68–69
National Domestic Preparedness Consortium, 228
National Health Account data, 135
National Health Information Infrastructure (NHII), 13–16, 27–28, 108, 159, 165–170, 173, 175, 177
National Healthcare Quality Report (NHQR), 68–69
National Library of Medicine (NLM), 17, 155, 180
Medline Plus, 151
Partners in Information Access for the Public Health Workforce, 159
National Network of Libraries of Medicine, 17, 155, 180
National Quality Forum (NQF), 33, 69, 75, 121n
National quality movement, 21, 53
National Rural Health Association, 89
National Rural Recruitment and Retention Network, 102
National Voluntary Hospital Reporting Initiative, 65, 122
Native Americans, 1, 17, 38, 92, 236
Networking, among rural providers, 179
Nonfederal physician specialty services, communities with, 223
Nurse practitioners, providing primary care, 83, 224
Nurses
formal education programs for, 96
full-time hospital-based, in rural counties, 232
recommendations for strengthening training programs for, 10, 112
Nursing Home Compare, 69
O
Obesity among women, self-reported in rural communities, 3, 39
Office of Management and Budget (OMB), 17, 167, 200–201
Office of Rural Health Policy (ORHP), 5–7, 9, 56, 74, 111, 169
designating to coordinate rural health input, 14, 170
Office of the National Coordinator for Health Information Technology, 13–15, 17, 166, 169–170, 173, 175, 180
Older Americans, rural, 20, 209
On-call resource center, providing to assist communities in implementing new technologies, 17, 180
Ongoing educational assistance, 178–180
Ongoing pay-for-performance studies, 121–123
Online information sources, providing access to, 17, 180
Open EHR Pilot Project, 174
Oral health care, in rural health care delivery, 238–240
Oral Health in America, 238
P
Paper-based information, 87
Parks, availability of, 45
Partners in Information Access for the Public Health Workforce, 159
Patient-centered care, 8
health professionals providing, 81–82
in improving population health and personal health care, 45–46
and the quality of care in rural communities, 35
Patient-level safety improvement strategies, 43
Patient monitoring, distance consultations and, 156–157
Patient privacy laws, in adopting ICT in rural settings, 166–167
Patient safety practices, 33
Patients, traveling long distances to provider sites, 47
Pay-for-performance programs, 11, 70, 120–126, 140–141
challenges facing rural providers, 123–124
establishing demonstration projects in rural communities, 11–12, 140–141
major ongoing pay-for-performance studies, 121–123
objectives, approaches, and measures, 124–126
Pediatricians, cross-training of, 95, 99
Performance measures, standardized, 63–65
Personal health care programs in rural areas, establishing Rural Quality Initiatives to measure and improve, 6–7, 74–75
Personal health needs, 4–5
at the community level, 3
Personal health records (PHRs), 152, 160, 162–163
Pew Internet and American Life Project, 161
Pharmacists
formal education programs for, 99
providing primary care, 83, 224–225
Physical exercise, lack of regular in rural communities, 3, 39
Physical infrastructures, 20
Physical therapy technicians, 83
Physician assistants
formal education programs for, 96–97
providing primary care, 224
Physician office link, in Bridges to Excellence, 121
Physician Shortage Area Program (PSAP), 93
Physicians
communities with nonfederal physician specialty services, 223
cross-training of, 100
equity of payments to, 12
formal education programs for, 93–96
J-1 waiver, 103
providing primary care, 222–224
specialist, 222–223
Pilot projects, 11
Pipeline, for the rural workforce, 80, 90
Population change in rural populations, 204–207
growth rates by race and ethnicity, 210
metropolitan, rural, and frontier areas, 207
rural-urban continuum code classifications, 206
Population health care programs in rural areas
establishing Rural Quality Initiatives to measure and improve, 6–7, 74–75
ICT applications in, 158–159
Population health needs, 4–5
at the community level, 3
Practice guidelines, 63
Premier, Inc., a quality incentive demonstration project, 122–123
President’s Information Technology Advisory Committee, 159
Primary care clinicians in rural health care delivery, 221–225
broader scope of practice for, 83
communities with nonfederal physician specialty services, 223
nurse practitioners, 224
pharmacists, 224–225
physician assistants, 224
physicians, 222–224
Primary care settings in rural health care delivery, 225–226
Priority Areas for National Action: Transforming Health Care Quality, 24
Professional associations, 9
Professionals
finding qualified health care, 3
Programs to provide core competencies for health professionals, 87–89
Prospective Payment System, 69, 72, 126–127, 130–131, 133
Public and private programs providing support for mental health and substance abuse services in rural areas, 13, 142
Public financing, 27
Public health capacity, 25
Public health care, in rural health care delivery, 241–242
Public health expenditures, 135–137
Public Health Functions Working Group, 242
Public health professionals, formal education programs for, 101–102
Public Health Security and Bioterrorism Preparedness and Response Act of 2002, 137
Public Health Service Act, 8, 88, 102, 225
Public Health Threats and Emergencies Act of 2000, 136
Public policies, regarding smoking, 45
Public reporting
concerns raised by, 70
in measuring and improving personal and population health care programs in rural areas, 7, 75
Public reporting programs, 68–70
Leapfrog Group, 69
Medical Compare, 69
National Healthcare Quality Report, 68–69
Public transportation, lack of, 47
Q
Qualified applicants, attracting from rural areas, 10, 112
Qualified health care professionals, shortages of, 3
Qualis Health, 67
Quality challenge in a rural context, 2–3, 85
Quality Chasm series, xi–xii, 2, 5–6, 22–24, 30–33, 38, 41, 51, 55, 80–82, 119–120, 125, 142, 147
Quality improvement activities in rural areas, 8, 60–77
accreditation and certification programs, 72–73
applying to core competencies for health professionals, 8, 85–87
clinical knowledge and associated tools, 63
current state of quality improvement efforts in rural areas, 6, 66–73
enhancing, 40
key components of a comprehensive quality improvement program, 61–66
knowledge of the science of quality and safety improvement, 61–62
performance measurement and data feedback capabilities, 65
processes and resources for, 65–66
public reporting programs, 68–70
quality improvement organizations, 66–68
quality improvement processes and resources, 65–66
recommendations for support structure, 6–7, 73–75
standardized performance measures, 63–65
support structures for, 3
targeted rural quality programs, 71–72
Quality Improvement Organization Support Center (QIOSCs), 7, 68, 75
Quality Improvement Organizations (QIOs), 66–68, 71, 75, 86, 89
Medicare, 66
Quality Interagency Coordinating Committee, 75
Quality movement, national, 21, 53
Quality of care in rural communities, 31–38
effectiveness of, 34–35
efficiency of, 36–37
equity in, 37–38
patient-centeredness of, 35
safety of, 32–34
shortcomings in, 80
timeliness of, 35–36
Quality of mental health and substance abuse services in rural areas, 12–13, 142
Quentin Burdick Rural Program for Interdisciplinary Training, 8, 88, 110
R
Race
educational attainment by, 215
population growth rates in rural populations by, 210
Racial and ethnic trends, in rural populations, 68, 210–211
RAND Corporation, 32
Rapid-cycle experimentation, 5
Recommendations
for an integrated approach to improving health and health care in rural communities, 52
for better utilizing information and communications technology, 14–17, 169–180
for financing, 140–142
for human resources, 109–113
for personal and population health needs, 5, 54–56
for providing adequate and targeted
financial resources, 11–13, 140–142
for quality improvement activities in rural areas, 73–75
for quality improvement support structure, 6–7, 74–75
for rural health care in the digital age, 168–181
for strengthening human resources, 8–11, 109–112
Recreational facilities, availability of, 45
Recruitment of the rural health professions workforce, 102–103
Redesign of health systems, providing leadership training to rural communities engaged in, 5, 56
Reform demonstrations, toward a comprehensive health system, 5, 54–56
Reforms to improve quality of rural health care, 80–89
basing services available on the population health needs of the local community, 26
core competencies for health professionals, 81–87
ensuring that a core set of health care services is available, 25–26
establishing links to services in other locales that cannot be delivered locally, 26
explicitly addressing the special circumstances of rural areas in health care financing, 27
focusing on rural communities in developing local and national health information technology infrastructures, 27
guiding principles for, 25–27
improving population health in addition to meeting personal health care needs, 25
programs to provide the core competencies, 87–89
shaping and guiding rural health care services by local community and rural organizations and institutions, 26
teams of well-trained health care clinicians, managers, and leaders working together, 26–27
Regenstrief Institute, 175
Regional information and communications technology/telehealth resource centers, 17, 178–180
Registered Nurse-Bachelor of Science in Nursing Satellite Program, 96
Registered nurses in rural counties, full-time hospital-based, 232
Remote language, and cultural interpretation, 154
Remoteness from urban areas, 1, 20
Residency training programs, federally-funded financial incentives for, 10, 112
Residents, role in chronic disease management, 107
Resource centers, for regional information and communications technology/telehealth, 17, 178–180
Resource context, standardized performance measures in scarcer and more diverse, 64
Response times by emergency medical personnel, 35, 47
Retention of the rural health professions workforce, 104–106
Retrieval, of diagnostic and health information, 156
Rewarding Results program, 121–122
Robert Wood Johnson Foundation, 52, 121
Partnerships for Training Program, 97
Practice Sites Program, 104
Turning Point: Collaborating for a New Century of Public Health Initiatives, 158
ROME (Rural Opportunities in Medical Education), 94
Rosenblatt, Roger, 197–198
Rural America, defining, xi–xii, 1–3, 19, 200–20
Rural Americans, deserving access to full spectrum of high-quality, appropriate health care, 25
Rural areas
population change in, 207
quality improvement activities in, 60–77
Rural Assistance Center, 89
Rural Broadband Loan and Loan Guarantee Program, 170, 201
Rural Clearinghouse for Lifelong Learning and Development, 215
Rural communities
Department of Health and Human Services meeting the needs of, 6
engaged in health system redesign, providing leadership training to, 5, 56
establishing relationships with health care providers and institutions in urban settings, 26
flexibility and assistance needed by, 6
health care organizations in, 1
professionals in, 1
siting portions of the educational experience in, 10, 112
Rural communities accessing and using the Internet for health-related applications, 14–15, 170–172
Rural disparities, 68
Rural emergency medical services, 226–229
funding, 134–135
Rural EMS Initiative, 97
Rural focus, incorporating into NHII planning and developmental activities, 14, 169–170
Rural health care
greater use of midlevel professionals, 83
renaissance in, 21
Rural health care delivery systems, 27, 220–248
hospital care, 229–230
improving, 23
long-term care, 230–234
mental health and substance abuse care, 234–238
oral health care, 238–240
persistence of underresourced infrastructure in, 3
primary care clinicians, 221–225
primary care settings, 225–226
public health care, 241–242
Rural health care in the digital age, 147–190
accelerating the adoption of ICT in rural settings, 165–168
consistent regulatory and payment policies, 172–173
current status of ICT in health care, 159–165
financial assistance for EHRs, 173–175
high-speed access to the Internet, 170–172
ICT applications in rural settings, 150–159
ICT collaborations and demonstrations in rural areas, 175–178
ongoing educational assistance, 178–180
recommendations, 168–181
rural focus in the NHII plan, 169–170
Rural health care institutions, capital and financial support for, 27
Rural Health Care Program, 15
expanding to include all rural providers, 15, 172
Rural health clinics, 125, 225–226
regional conferences for, 7
“Rural health network,” 179n
Rural health policy, 20–22, 45
Rural health professions workforce, 89–106
attracting rural students to health careers, 91–92
enhancing, 40
formal education programs, 92–102
recruitment, 102–103
retention, 104–106
the rural workforce pipeline, 80, 90
skill set of, 80
Rural health providers
historical underpayment of, 12
mentoring program for, 9
Rural health providers converting to electronic health records, 15–16, 173–175
Rural Health Research Center, 137
Rural Health Support Mechanism, 171–172
Rural Healthy People 2010 report, 239
Rural Hospital Flexibility Grant Program, 71, 86
Rural Medical Education Program, 94
Rural mental health and substance abuse services, funding of, 139–140, 142
Rural Physician Program, 94
Rural populations, 200–219
defining rural America, 200–204
the digital divide, 216–217
education and literacy, 213–216
educational attainment by race, 215
health insurance, 217–218
higher rates of limitations among, 3
income and employment, 212–213
population change, 204–207
population growth rates by race and ethnicity, 210
racial and ethnic trends, 210–211
rural older Americans, 209
Rural Quality Advisory Panel, 6–7, 74–75
Rural Quality Initiative, 6, 74–75
applying evidence to practice, 7, 75
community-based technical assistance, 7, 75
establishing to measure and improve personal and population health care programs in rural areas, 6–7, 17, 74–75
standardizing measure set for rural communities, 7, 75
Rural referral centers, 20
Rural Research Center, 137
Rural resources for dental care, 131–132
Rural training tracks and fellowships, developing, 10, 112
Rural/Underserved Opportunities program, 94
Rural-urban continuum code classifications, 206
Rural Utilities Service, 170
S
Safety
in improving population health and personal health care, 41–43
of quality of care in rural communities, 32–34
as a system priority, 85
Safety improvement, scientific knowledge of, 61–62
Scarce resource context, standardized performance measures in, 64
School-based health, 25
School leadership, outreach to, 41
Science of quality and safety improvement, knowledge of, 61–62
Section 242 Program. See Hospital Mortgage Insurance Program
Secure platforms for data exchange, establishing, 27
Self-Determination Act, 16, 175
Self-reported obesity, among women in rural communities, 39
Serious emotional disturbance, defined, 234n
Serious mental illness, defined, 234n
Sign language interpretation, 154
Size, Tim, 198
Small Hospital Improvement Program (SHIP), 71–72
Small rural provider settings, 6
standardized performance measures in, 64
Smoking
increased likelihood of in rural communities, 3, 38–39
public policies regarding, 45
Social behaviors, influence on the health of individuals and populations, 4
Social infrastructures, 20
Social Security Act, 176
Social support, for the disadvantaged and handicapped, 25
Sole community hospitals, 20–21
Southern Rural Access Program, 102, 138
Specialist physicians, 222–223
Stability, financial, of rural health care providers, 3, 12, 40, 141–142
Standardized performance measures for rural communities, 63–65
community hub role, 64
first-contact and linking roles, 64
measuring and improving personal and population health care programs, 7, 75
scarcer and more diverse resource context, 64
small rural provider settings, 64
State education agencies, 10
State financial conditions, worsening, 12
State Offices of Rural Health, 89
Storage, of diagnostic and health information, 156
Students, loan repayment programs for disadvantaged, 8
Studies, major ongoing pay-for-performance, 121–123
Subject-specific skills, for public health professionals, 102
Substance abuse
defined, 234n
See also Mental health and substance abuse services
Substance Abuse and Mental Health Services Administration (SAMHSA), 21, 142
Surgeon General, 238–239
Sustainable growth rate (SGR) formula, 130
T
Targeted rural quality programs, 71–72
targeting workforce training programs more effectively, 9, 110–111
Technical requirements of health care, 164–165
providing assistance with, 17, 180
Technology/telehealth resource centers, establishing regional information and communications, 17, 178–180
Telecommunications access networks, surcharges for transfer of health messages across, 15, 172
Telecommunications Act of 1996, 171
Telecommuting, to jobs in urban areas, 1
Teleconsultations, 156
Telehealth resource centers, 17, 178–180
Telehealth services, 149, 163–165
identifying barriers to, 15, 173
Telemedicine, 15, 153, 156, 163–164
Teleneurology diagnostics, 156
Telepsychiatry, 157
Tertiary centers, 63
Timeliness, 38
of improving population health and personal health care, 45, 47–48
of quality of care in rural communities, 35–36
Titles VII and VIII, 8, 88, 102, 110
To Err Is Human: Building a Safer Health System, xi, 31, 33
Training of emergency medical technicians, levels of, 226–227
Training programs, experientially based in rural areas, 8–9, 109–110
Transfer of health messages across telecommunications access networks, prohibiting surcharges for, 15, 172
Transfer services, 6
Traveling long distances to provider sites, 47
Trends, racial and ethnic, in rural populations, 210–211
Turning Point: Collaborating for a New Century of Public Health Initiatives, 158
U
Underpayment of rural health providers, historical, 12
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 37
Uninsurance rates in rural areas, 20, 27, 211, 217
Universal Service Administrative Company
E-rate Program, 172
Rural Health Support Mechanism, 171–172
Universal Service Fund, Rural Health Care Program, 15
Urban areas
commuting to jobs in, 1
U.S. health care system, calls for fundamental reform of, 2
Utilization of informatics, by health professionals, 87
V
Veterans Health Administration (VHA), 174, 225
Video-based telemedicine conferencing, 153
W
W. K. Kellogg Foundation, 5, 21
Leadership for Community Change Program, 5, 52, 56
Walsh Center for Rural Health Analysis, 137
Watson, Linda, 198–199
Web-based communication, 60–62, 84
WiMax technologies, 171
Women, self-reported obesity among, in rural communities, 39
Workforce training programs
expanding experientially based in rural areas, 8–9, 109–110
targeting more effectively, 9, 110–111
Working in interdisciplinary teams, by health professionals, 83–84
Workplace basics, for public health professionals, 102
Z
Zero-sum choices, 43