Judith Ortiz

Transitional Care: Looking for the Right Shoes to Fit Older Adult Patients

Potentially avoidable hospitalizations are associated with high costs and an increased risk for iatrogenic conditions in older adult patients. Although care managers may be aware of the common potential pitfalls that may arise in the transfer of patients to and from the hospital, defining best practice models has been difficult. Many current models of geriatric care have had little or no impact on lowering the rates of hospitalizations and rehospitalizations when formally studied. Health care reform legislation mandates initiatives involving new models of coordinated or guided care such as the medical home model and the accountable care organization. These new models too will face significant challenges in their attempt to provide the financial incentives and systematic changes needed to successfully address transitional care in older adults.

TRENDS IN RURAL HEALTH CLINICS AND NEEDS DURING U.S. HEALTH CARE REFORM

AIM Rural Health Clinics (RHCs) are primary care clinics certified through Medicare and Medicaid to provide health care to the medically underserved in rural areas of the United States. The purpose of this paper is to describe how the characteristics of RHCs have either changed or remained stable over a 10-year period in the past: from the late 1990s to 2007. In addition, it is also to describe some of the outstanding needs of RHCs as they navigate the transitions of U.S. health care reform. METHODS Using a panel of RHCs continuously in existence from 2006 through 2007, we calculated and compared statistics with corresponding statistics from the literature. We described the geographic distribution of RHCs, demographics of their counties of location, and characteristics of RHC structure and staffing. We also explored the implications of the recently enacted health reform law (the Patient Protection and Affordable Care Act or ACA) for RHCs, and the improvements that RHCs need as it is implemented. FINDINGS By the end of the study period, the highest percentages of RHCs were in the South and Midwest, the percentage of RHCs in the West had grown, and that in the South had declined. RHCs served counties with increasing proportions of individuals below poverty and Hispanics/Latinos. The percentage of independent clinics had grown, as had the percentage of for profit clinics. Finally, the percentage of nurse practitioner full-time equivalents had grown as a proportion of the total for three providers. CONCLUSIONS In investigating the performance of RHCs, many managerial and operational factors are not well understood. It is imperative that RHCs gather the information that could help them maximize the elements of their performance that would keep them financially stable. In addition, a broader awareness of the unique challenges that RHCs face in this era of health care reform is needed.

Rural Health Clinic Efficiency and Effectiveness: Insight from a Nationwide Survey

This study reports the results of a nationwide survey of Rural Health Clinics (RHCs). The purpose was to identify factors that contribute to efficiency and effectiveness in RHCs. Factors related to cost efficiency were analyzed using multiple regression; factors related to the likelihood of providing preventive diabetic care, an effectiveness indicator, were analyzed using logistic regression. The study found: (1) technical efficiency to be positively related to cost efficiency; (2) non-profit control to be inversely related to cost efficiency in independent RHCs; and (3) provider-based RHCs and technology use to be related to the likelihood of providing preventive diabetic care. Implications for RHCs are: (1) improvement in technical efficiency could enhance cost efficiency; (2) visits to PAs and NPs, an indicator of process efficiency, may not guarantee the provision of preventive diabetic care; and (3) strategies for improving RHC efficiency and effectiveness may be different for provider-based and independent clinics.

Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics

Purpose: To identify organizational and environmental correlates to rural health clinics’ preventive quality of care in the United States. Design: A retrospective observational cohort study design was applied under Donabedian’s Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients. Methods: Structural equation modeling with maximum likelihood estimation was used. Findings: Provider affiliation (P = .03), absence of physicians (P = .007), and higher proportion of nonphysicians (P = .007) were negatively related to preventive quality of care. Lower cause-specific mortality rate at the county level as compared to the United States average (P = .05) and rural location (P = .001) were positively related to quality of care. Implications: The results of the study showed the need to attract and retain physicians in rural health clinics. The positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.

Willingness to participate in accountable care organizations: health care managers' perspective.

This study examines how health care managers responded to the accountable care organization (ACO). The effect of perceived benefits and barriers of the commitment to develop a strategic plan for ACOs and willingness to participate in ACOs is analyzed, using organizational social capital, health information technology uses, health systems integration and size of the health networks, geographic factors, and knowledge about ACOs as predictors. Propensity score matching and analysis are used to adjust the state and regional variations. When the number of perceived benefits is greater than the number of perceived barriers, health care managers are more likely to reveal a stronger commitment to develop a strategic plan for ACO adoption. Health care managers who perceived their organizations as lacking leadership support or commitment, financial incentives, and legal and regulatory support to ACO adoption were less willing to participate in ACOs in the future. Future research should gather more diverse views from a larger sample size of health professionals regarding ACO participation. The perspective of health care managers should be seriously considered in the adoption of an innovative health care delivery system. The transparency on policy formulation should consider multiple views of health care managers.

Racial Disparities in Diabetes Hospitalization of Rural Medicare Beneficiaries in 8 Southeastern States

This study examined racial variability in diabetes hospitalizations attributable to contextual, organizational, and ecological factors controlling for patient variabilities treated at rural health clinics (RHCs). The pooled cross-sectional data for 2007 through 2013 for RHCs were aggregated from Medicare claim files of patients served by RHCs. Descriptive statistics were presented to illustrate the general characteristics of the RHCs in 8 southeastern states. Regression of the dependent variable on selected predictors was conducted using a generalized estimating equation method. The risk-adjusted diabetes mellitus (DM) hospitalization rates slightly declined in 7 years from 3.55% to 2.40%. The gap between the crude and adjusted rates became wider in the African American patient group but not in the non-Hispanic white patient group. The average DM disparity ratio increased 17.7% from the pre-Affordable Care Act (ACA; 1.47) to the post-ACA period (1.73) for the African American patient group. The results showed that DM disparity ratios did not vary significantly by contextual, organizational, and individual factors for African Americans. Non-Hispanic white patients residing in large and small rural areas had higher DM disparity ratios than other rural areas. The results of this study confirm racial disparities in DM hospitalizations. Future research is needed to identify the underlying reasons for such racial disparities to guide the formulation of effective and efficient changes in DM care management practices coupled with the emphasis of culturally competent, primary and preventive care.

Variations in Colorectal Cancer Screening of Medicare Beneficiaries Served by Rural Health Clinics.

This study aims (1) to examine the trends and patterns of colorectal cancer screening (CCS) of Medicare beneficiaries in rural areas by state and year (before and after Affordable Care Act [ACA] enactment) and (2) to investigate the contextual, organizational, and aggregated patient characteristics influencing variations in care received by patients of rural health clinics (RHCs). The following 2 hypotheses were formulated: (1) CCS rates are higher in the post-ACA period than in the pre-ACA period, irrespective of the factors rurality, poverty, dually eligible status, and the organizational characteristics of RHCs and (2) the contextual and organizational factors of RHCs exert more influence on the variation in CCS rates of RHC patients than do aggregated personal factors. We used administrative data on CCS rates (2007 through 2012) for rural Medicare beneficiaries. Autoregressive growth curve modeling of the CCS rates was performed. A generalized estimating equation of selected predictors was analyzed. Of the 9 predictors, 5 were statistically significant: The ACA and the percentage of female patients had a positive effect on the CCS rate, whereas regional location, years of RHC certification, and average age of patients had a negative effect on the CCS rate. The predictors accounted for 40.2% of the total variance in CCS. Results show that in rural areas of 9 states, the enactment of ACA improved CCS rates, contextual, organizational, and patient characteristics being considered. Improvement in preventive care will be expected, as the ACA is implemented in the United States.

Primary Care Clinics and Accountable Care Organizations

Background: The Accountable Care Organization (ACO) is one of the new models of health care delivery in the United States. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods: A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables—participation in ACOs and willingness to join ACOs—were created and analyzed using a generalized estimating equation approach. Results: A total of 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. Rural Health Clinics in isolated areas were 78% less likely to be in ACOs (odds ratio = 0.22, P = .059). Nonprofit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B = 1.271, P = .054). There is a positive relationship between RHC size and willingness to join an ACO (B = 0.402, P = .010). Conclusion: At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs.

Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes

Background: For decades, U.S. rural areas have experienced shortages of primary care providers. Nurse practitioners (NPs) are helping to reduce that shortage. However, NP scope of practice regulations vary from state-to-state ranging from autonomous practice to direct physician oversight. The purpose of this study was to determine if clinical outcomes of older rural adult patients vary by the level of practice autonomy that states grant to NPs. Methods: This cross-sectional study analyzed data from a sample of Rural Health Clinics (RHCs) (n = 503) located in eight Southeastern states. Independent t-tests were performed for each of five variables to compare patient outcomes of the experimental RHCs (those in “reduced practice” states) to those of the control RHCs (in “restricted practice” states). Results: After matching, no statistically significant difference was found in patient outcomes for RHCs in reduced practice states compared to those in restricted practice states. Yet, expanded scope of practice may improve provider supply, healthcare access and utilization, and quality of care (Martsolf et al., 2016). Conclusions: Although this study found no significant relationship between Advanced Registered Nurse Practitioner (ARNP) scope of practice and select patient outcome variables, there are strong indications that the quality of patient outcomes is not reduced when the scope of practice is expanded.

Contextual, Ecological and Organizational Variations in Risk-Adjusted COPD and Asthma Hospitalization Rates of Rural Medicare Beneficiaries.

The purpose of this study is to examine what factors contributing to the variability in chronic obstructive pulmonary disorder (COPD) and asthma hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method. A longitudinal analysis of COPD and asthma hospitalization of rural Medicare beneficiaries in 427 rural health clinics (RHCs) was conducted utilizing administrative data and inpatient and outpatient claims from Region 4. The repeated measures of risk-adjusted COPD and asthma admission rate were analyzed by growth curve modeling. A generalized estimating equation (GEE) method was used to identify the relevance of selected predictors in accounting for the variability in risk-adjusted admission rates for COPD and asthma. Both adjusted and unadjusted rates of COPD admission showed a slight decline from 2010 to 2013. The growth curve modeling showed the annual rates of change were gradually accentuated through time. GEE revealed that a moderate amount of variance (marginal R2 = 0.66) in the risk-adjusted hospital admission rates for COPD and asthma was accounted for by contextual, ecological, and organizational variables. The contextual, ecological, and organizational factors are those associated with RHCs, not hospitals. We cannot infer how the variability in hospital practices in RHC service areas may have contributed to the disparities in admissions. Identification of RHCs with substantially higher rates than an average rate can portray the need for further enhancement of needed ambulatory or primary care services for the specific groups of RHCs. Because the risk-adjusted rates of hospitalization do not very by classification of rural area, future research should address the variation in a specific COPD and asthma condition of RHC patients. Risk-adjusted admission rates for COPD and asthma are influenced by the synergism of multiple contextual, ecological, and organizational factors instead of a single factor.