Paul McGinnis

Community characteristics affecting emergency department use by Medicaid enrollees.

Objectives:In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. Methods:This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. Results:ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: −0.044, −0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes’ drive had 0.26 (95% CI: −0.38, −0.13) fewer ED visits/person/yr. Conclusions:Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems–augmenting access to care and reducing reliance on EDs.

Practice-based Research is Community Engagement

Community engagement has become a major contributor to medical research during the past 10 years and is an essential component of the current National Institutes of Health (NIH) Roadmap and the Clinical and Translational Science Awards program.[1][1][,2][2] But, what is a community? And what

Unmet Dental Needs in Rural Primary Care: A Clinic-, Community-, and Practice-based Research Network Collaborative

Background: Oral health is an essential component of general health and well-being, yet barriers to the access of dental care and unmet needs are pronounced, particularly in rural areas. Despite associations with systemic health, few studies have assessed unmet dental needs across the lifespan as they present in primary care. This study describes the prevalence of oral health conditions and unmet dental needs among patients presenting for routine care in a rural Oregon family medicine practice. Methods: Eight primary care clinicians were trained to conduct basic oral health screenings for 7 dental conditions associated with International Statistical Classification of Diseases and Related Health Problems 9—Clinical Modification codes. During the 6-week study period, patients older than 12 months of age who presented to the practice for a regularly scheduled appointment received the screening and completed a brief dental access survey. Results: Of 1655 eligible patients, 40.7% (n = 674) received the screening and 66.9% (n = 1108) completed the survey. Half of the patients who were screened (46.0%, n = 310) had oral health conditions detected, including partial edentulism (24.5%), dental caries (12.9%), complete edentulism (9.9%), and cracked teeth (8.9%). Twenty-eight percent of the patients reported experiencing unmet dental needs. Patients with dental insurance were significantly more likely to report better oral and general health outcomes as compared with those who had no insurance or health insurance only. Conclusions: Oral health diseases and unmet dental needs presented substantially in patients with ages ranging across the lifespan from one rural primary care practice. Primary care settings may present opportune environments for reaching patients who are unable to obtain regular dental care.

Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers.

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

Transitioning from CHIP to CHIRP: blending community health development with community-based participatory research.

In 2006, a community health development model was used to engage citizens in Jefferson County, Oregon, around local health concerns. Childhood obesity emerged as a priority health issue. In 2007, a research component was introduced by Oregon Health & Science University to help the community garner resources and inform the field. This case study describes the collaboration between the Mountain View Community Health Improvement Partnership and Oregon Health & Science University to increase the number of county children at a healthy weight. Research and projects occurred simultaneously since community members are motivated by action, and research is a slower process.

Engaging the Underserved: A Process Model to Mobilize Rural Community Health Coalitions as Partners in Translational Research†

Community engagement (CE) and community‐engaged research (CEnR) are increasingly recognized as critical elements in research translation. Process models to develop CEnR partnerships in rural and underserved communities are needed.

Calorie Labeling in a Rural Middle School Influences Food Selection: Findings from Community-Based Participatory Research

Background. Calorie labeling at the point-of-purchase in chain restaurants has been shown to reduce energy intake. Objective. To investigate the impact of point-of-purchase calorie information at one rural middle school. Methods. With a community-based participatory research framework a mixed method approach was used to evaluate the impact of point-of-purchase calorie information. Students in grades 6–8, dining at the school cafeteria January and February 2010, participated for 17 school days each month; in January a menu was offered in the usual manner without calorie labels; the same menu was prepared in February with the addition of calorie labels at point-of-purchase. Gross calories served per student were measured each day allowing for matched comparison by menu. In March/April of 2010, 32 students who ate in the cafeteria 3 or more times per week were interviewed regarding their views on menu labeling. Results. Calorie consumption decreased by an average of 47 calories/day; fat intake reduced by 2.1 grams/day. Five main themes were consistent throughout the interviews. Conclusion. Point-of-purchase calorie labels can play a role in reducing the number of calories consumed by middle school age children at the lunch. The majority of students interviewed found the calorie labels helped them choose healthier food.

Milk Options Observation (MOO): A Mixed-Methods Study of Chocolate Milk Removal on Beverage Consumption and Student/Staff Behaviors in a Rural Elementary School

Providing flavored milk in school lunches is controversial, with conflicting evidence on its impact on nutritional intake versus added sugar consumption and excess weight gain. Nonindustry-sponsored studies using individual-level analyses are needed. Therefore, we conducted this mixed-methods study of flavored milk removal at a rural primary school between May and June 2012. We measured beverage selection/consumption pre- and post-chocolate milk removal and collected observation field notes. We used linear and logistic mixed models to assess beverage waste and identified themes in staff and student reactions. Our analysis of data from 315 unique students and 1,820 beverages choices indicated that average added sugar intake decreased by 2.8 g postremoval, while average reductions in calcium and protein consumption were negligible (12.2 mg and 0.3 g, respectively). Five thematic findings emerged, including concerns expressed by adult staff about student rebellion following removal, which did not come to fruition. Removing flavored milk from school-provided lunches may lower students’ daily added sugar consumption without considerably decreasing calcium and protein intake and may promote healthy weight.

Rural Oregon Community Perspectives: Introducing Community-Based Participatory Research into a Community Health Coalition

The Community Health Improvement Partnership (CHIP) model has supported community health development in more than 100 communities nationally. In 2011, four rural Oregon CHIPs collaborated with investigators from the Oregon Rural Practice-based Research Network (ORPRN), a component of the Oregon Clinical and Translational Research Institute (OCTRI), to obtain training on research methods, develop and implement pilot research studies on childhood obesity, and explore matches with academic partners. This article summarizes the experiences of the Lincoln County CHIP, established in 2003, as it transitioned from CHIP to Community Health Improvement and Research Partnership (CHIRP). Our story and lessons learned may inform rural community-based health coalitions and academicians who are engaged in or considering Community-based participatory research (CBPR) partnerships. Utilizing existing infrastructure and relationships in community and academic settings provides an ideal starting point for rural, bidirectional research partnerships.