Alana Knudson

Current practices and state regulations regarding telepharmacy in rural hospitals

PURPOSE Telepharmacy practices in rural hospitals in several states were examined, and relevant policies and state laws and regulations were analyzed, along with issues to be addressed as the use of telepharmacy expands. METHODS Telepharmacy initiatives in rural hospitals were identified through a survey of the 50 state offices of rural health. Telephone interviews were conducted with board of pharmacy directors in selected states with successful telepharmacy programs. Interviews were also conducted with the individual hospitals regarding the type of telepharmacy activities, funding, and impact on medication safety. The information was analyzed to identify themes and to assess whether state laws and regulations followed recommendations by the National Association of Boards of Pharmacy (NABP) and the American Society of Health-System Pharmacists. RESULTS Although telepharmacy is addressed in NABPs model pharmacy practice act, many state boards are just beginning to address it. The model act addresses the practice of pharmacy across state lines, and the state board directors interviewed generally agreed that pharmacists should be licensed in the state where they are providing the service. States differed on whether a pharmacist should be required to be physically located in a licensed pharmacy and how much time the pharmacist should have to spend onsite. Telepharmacy models being implemented in hospitals in several states incorporate long-distance supervision of pharmacy technicians by pharmacists. The models being implemented vary according to area, state regulations, hospital ownership, and hospital size and medication order volume. Most hospitals reported that they track medication error rates, and some said error rates have improved since telepharmacy implementation. CONCLUSION The application of telepharmacy in rural hospitals varies across the United States but is not widespread, and many states have not defined regulations for telepharmacy in hospitals.

Disparities in pediatric asthma hospitalizations.

OBJECTIVE The purpose of this project was to determine to what extent rural children are hospitalized for asthma, an ambulatory care sensitive condition defined by the Agency for Healthcare Research and Quality pediatric quality indicators; to analyze differences in hospitalization rates for asthma by state and by rurality; and to examine the relationships between asthma hospitalization rates and poverty, health insurance, and physician supply. METHODS The project used 2001 through 2004 hospital inpatient discharge data for children aged 2 to 17 years from six geographically diverse states in the Healthcare Cost and Utilization Project. County-level poverty, uninsurance estimates, and physician data came from the 2004 Area Resource File. Pediatric Quality Indicator software was used to calculate county-level admission rates for asthma. Multivariate regression models were specified to assess how sensitive hospitalization rates were to characteristics of the childrens counties of residence. RESULTS Pediatric asthma hospitalization rates per 100,000 children aged 2 to 17 years varied by state ranging from 51.1 to 185.9. When comparing all six states, rural children were the most likely to be hospitalized for asthma. However, after controlling for rurality, poverty, uninsurance, and physician supply, uninsurance was the only variable to significantly impact hospitalization rates. CONCLUSIONS These findings indicate that there are significant differences in pediatric asthma hospitalizations rates by and within states, which may best be addressed by targeting public health and healthcare interventions. In addition, the findings support efforts to increase health insurance coverage for children, especially rural children who are less likely to be insured.

Why is rural public health important? A look to the future.

Public health in the United States began as a largely urban phenomenon, dating back to the late 1700s. In those days, public health was mostly concerned with issues such as sanitation and communicable diseases, which were of greater concern in areas with higher population density. By the late 1800s, however, it was apparent that the countrys population was becoming more mobile and communicable diseases were beginning to spread from urban dwellers to rural dwellers, creating a need for rural public health services. Beginning in 1908, local governmental public health began to expand its reach into rural areas, with county health departments developing rapidly until the mid-1940s. Following the passage of the Hill-Burton Act in 1945, which funded the construction of community hospitals, rural health focus shifted almost exclusively to ensuring access to healthcare services. This article provides a historical context for rural public health service delivery and a beginning discussion of implications for contemporary rural public health practice.

The Double Disparity Facing Rural Local Health Departments.

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland

OBJECTIVES To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDPs impact on dental-related visits to a regional emergency department (ED). METHODS We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. RESULTS The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in

Rural Collaborative Model for Diabetes Prevention and Management: A Case Study

215 000 more in charges. CONCLUSIONS Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. POLICY IMPLICATIONS Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed.

Enhancing mental health literacy in rural America: Growth of Mental Health First Aid program in rural communities in the United States from 2008–2016.

Diabetes disproportionately affects racial and ethnic minorities, rural, and impoverished populations. This case study describes the program components and key lessons learned from implementing Vivir Mejor! (Live Better!), a diabetes prevention and management program tailored for the rural, Mexican American population. The program used workforce innovations and multisector partnerships to engage and activate a rural, mostly Hispanic population. Community health worker (CHW) roles were designed to reach and support distinct populations. Promotoras focused exclusively on health education and patient navigators individually coached patients with chronic disease management issues for the high-risk patient population. To extend diabetes health education to the broader community in Santa Cruz County, promotoras trained lay leaders to become peer educators. Multisector partnerships allowed the program to offer health and social services around diabetes care. The partners also supported provider engagement through continuing education workshops and digital story screening to encourage referrals to the program. Multisector partnerships, including partnering with critical access hospitals, for diabetes management and prevention, as well as using different types of CHWs to implement programs that target high- and low-risk populations are innovative and valuable components of the Vivir Mejor! model.

The 2014 Update of the Rural-Urban Chartbook

There is a significant shortage of behavioral health and mental health providers in rural America. This study examines the spread of Mental Health First Aid (MHFA), a program aimed at increasing mental health literacy, with a focus on rural areas across the country and within each state. Between 2008 and 2016, 47,660 MHFA courses were offered, training approximately 777,000 individuals nationwide. Twenty-two percent of courses over this time period were offered in rural areas. The number of courses in rural areas increased from 3 in 2008 to 528 in 2012 and 3,330 in 2016. Over 167,850 rural-based individuals received training from 2008 to 2016. The spread of the MHFA program varied significantly across states. Among states in which 50% or more of the population live in rural areas, the proportion of courses taught in rural areas ranged from 42% to 78%, and the proportion of the rural population who had received training in these states ranged from 15 people per 10,000 to 74.8 people per 10,000. Although the program has spread to many communities, there are a large number of rural and urban communities yet to be reached.