Bettye A. Apenteng

Rural Veterans’ Perspectives of Dual Care

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans’ satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.

Preventable hospitalizations: Does rurality or non-physician clinician supply matter?

This study examines the relationship between rurality as well as the proportion of non-physician clinicians and county rates of ambulatory care sensitive hospitalizations (ACSHs) for pediatric, adult and elderly populations in Nebraska. The study design was a cross-sectional observational study of county level factors that affect the county level rates of ACSHs using Poisson regression models. Rural (non-metro) counties have significantly higher ACSHs for both pediatric and adult population, but not for the elderly. Frontier counties have significantly higher adult ACSHs. The proportion of primary care providers who are non-physician clinicians does not have a significant association with ACSHs for any of the age groups. The results indicate that rurality may have a greater impact on pediatric and adult ACSHs and the proportion of NPCs in the primary care provider workforce does not significantly impact ACSH rates.

Transitions in Dual Care for Veterans: Non-Federal Physician Perspectives

Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practising in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.

Frontier America's Health System Challenges and Population Health Outcomes

PURPOSE The objective of this cross-sectional descriptive study was to examine and compare the county-level characteristics including demographic factors, health system factors, and population health outcomes of frontier and nonfrontier counties in the United States. All counties in the United States were studied using the merged County Health Rankings 2011 and the Area Resource File 2009 databases. Of a total of 3,141 counties in the County Health Rankings 2011 database, 438 were identified as frontier counties using the conventional definition of fewer than 7 persons per square mile. FINDINGS Frontier counties were found to have a significantly higher proportion of elderly, Hispanic, and Native American residents than nonfrontier counties. Frontier counties have lower household income and lower levels of illiteracy. Frontier counties also have significantly fewer primary care physicians and higher uninsurance rates. Although frontier counties have a lower percentage of ZIP codes with healthy food and recreational facilities, the incidence of obesity is lower in frontier areas. CONCLUSIONS Empirical literature on the population health outcomes and health system factors of frontier areas is limited. Frontier communities in the United States face significant challenges in terms of having populations with a higher need for primary care such as the elderly and poor. In addition, they face access barriers due to geographic remoteness. The availability of reliable data on population outcomes will enable policy makers to monitor the health status of frontier populations and to design solutions to the access issues that these populations face.

Needs Assessment for Behavioral Health Workforce: a State-Level Analysis

This study describes trends in the supply and the need for behavioral health professionals in Nebraska. A state-level health workforce database was used to estimate the behavioral health workforce supply and need. Compared with national estimates, Nebraska has a lower proportion of all categories of behavioral health professionals. The majority of Nebraska counties have unusually high needs for mental health professionals, with rural areas experiencing a decline in the supply of psychiatrists over the last decade. Availability of robust state-level health workforce data can assist in crafting effective policy for successful systems change, particularly for behavioral health.

Science-based and practice-based innovativeness and performance of substance abuse treatment facilities.

BACKGROUND The fields of mental health and substance abuse treatment lag significantly behind other health care organizational fields in the adoption, implementation, and dissemination of evidence-based practices. Innovative organizational practices may be science based or practice based. The implementation of innovative practices requires considerable organizational resources. Whether this organizational investment actually pays off in terms of superior performance is unclear. This issue in the context of substance abuse treatment facilities (SATFs) in the United States is examined in this study. PURPOSE The purpose of this study is to examine the influence of the use of innovative organizational practices, both science based (psychosocial interventions) and practice based, on the organizational performance of SATFs. METHODOLOGY/APPROACH The study uses cross-sectional data on 13,513 SATFs in the United States, obtained from the National Survey of Substance Abuse Treatment Services 2009 database. FINDINGS Multinomial logistic regression models find a positive association between the use of science-based innovations and practice-based innovations and organizational performance, that is, the provision of comprehensive (core and wraparound) services. SATFs that were located in metropolitan areas, those accredited by the Commission on Accreditation of Rehabilitation Facilities and Joint Commission, that had a mixed (Substance Abuse and Mental Health) focus or were recipients of earmark funds also had higher organizational performance. PRACTICE IMPLICATIONS The results signify that substance abuse facilities that are high innovators in terms of implementing science based and practice-based innovative practices have higher organizational performance. Organizations that have institutionalized these practices have invested considerable resources in innovation. The shown higher organizational performance provides justification for the organizational investment in innovation.

Temporal Trends and Rural-Urban Differences in Hospital Length of Stay for Alzheimer Disease and Related Disorders

Objectives: The aim of this study was to assess rural-urban differences and temporal trends in length of inpatient stay among patients diagnosed with Alzheimer disease and related dementia (ADRD). Materials and Methods: The study sample comprised 27,313 ADRD and 27,313 matched non-ADRD inpatient discharges from Nebraska hospitals from 2005 to 2011. Descriptive statistics and multivariable regression models were used to assess rural-urban variations and temporal trends in length of stay (LOS). Results: LOS was found to be similar for ADRD and non–ADRD-related hospitalizations. No rural-urban differences in LOS were observed for ADRD-related hospitalizations. However, there was a temporal decline in LOS for ADRD-related hospitalizations. Conclusions: LOS for ADRD-related hospitalizations was found to be influenced mostly by patient-level demographic and clinical factors. Hospital-level factors were not associated with LOS.

Blood pressure control, glycemic control, and dyslipidemia among healthy adults in the Cape Coast metropolis, Ghana

BACKGROUND The World Health Organization recommends the implementation of interventions focused on the early detection of clinical risk factors for cardiovascular disease (CVD) as effective strategies for the control of CVD in low resource settings. However, due to health system resource constraints, surveillance capacity for the identification of high-risk populations for non-communicable diseases, including CVD have been inadequate. The purpose of this study was to describe the prevalence of CVD clinical risk factors among healthy adults residing in the Cape Coast metropolis of Ghana. The clinical risk factors assessed included glycemic control, insulin sensitivity, lipid control and blood pressure. METHODS The study participants included 70 healthy adults without a previous diagnosis of CVD from Cape Coast metropolis. Blood samples, blood pressure and anthropometric measurement were obtained for each participant. Serum glycated hemoglobin (HbA1c), insulin, glucose, triglycerides, and cholesterol levels were measured. RESULTS Approximately four out of ten participants were either overweight or obese. Almost three-quarters of the sample were considered prehypertensive or hypertensive. About three in ten were clinically prediabetic. About a third of the participants had high non-HDL cholesterol levels. Triglyceride concentration levels were found to be high in almost 10 percent of the study sample. Approximately six percent were identified as having metabolic syndrome. CONCLUSION A significant proportion of the study participants were identified to be at risk for CVD. There is the need for adaptive and less resource-intensive CVD risk-factor screening interventions to allow for the timely detection and management of CVD risk factors in low-resource settings.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska: Recruitment and Retention in Rural Nebraska

PURPOSE There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

A Comparative Assessment of Nebraska’s J1 visa waiver and State Loan Repayment Programs in the Recruitment and Retention of Physicians

PURPOSE There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.