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



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Quality Through Collaboration: The Future of Rural Health 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

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Quality Through Collaboration: The Future of Rural Health 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 resource centers for, 17, 178–180

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Quality Through Collaboration: The Future of Rural Health 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 recommendations to, 14–15, 54 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 utilizing informatics, 8, 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

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Quality Through Collaboration: The Future of Rural Health 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 nurses, 95, 99 of pediatricians, 95, 99 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 Decision support, 53, 154–156 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 Rural Task Force, 14, 169–170 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

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Quality Through Collaboration: The Future of Rural Health 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 E-encounters, 149, 154 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 response times by, 35, 47 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

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Quality Through Collaboration: The Future of Rural Health 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 analyzing, 12, 141–142 need for, 3, 40, 139 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 Frontier areas, 1, 17, 204 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

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Quality Through Collaboration: The Future of Rural Health 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

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Quality Through Collaboration: The Future of Rural Health 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 critical access, 21, 231 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 findings, 9–10, 110–111 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 efficiency of, 47, 49 equity in, 47, 50–51

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Quality Through Collaboration: The Future of Rural Health leadership and collaboration in, 51–52 patient- or community-centeredness of, 45–46 safety of, 41–43 timeliness of, 45, 47–48 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 findings, 15, 173 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

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Quality Through Collaboration: The Future of Rural Health 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 Kellogg Foundation, 5, 21, 52 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 Leapfrog Group, 33, 68–69 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

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Quality Through Collaboration: The Future of Rural Health 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 MedPAC, 130, 133 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 Health Service Corps (NHSC), 102–103, 236n

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Quality Through Collaboration: The Future of Rural Health 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 cross-training of, 95, 99 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 Operating margins, 6, 12 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

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Quality Through Collaboration: The Future of Rural Health Payment policies, 2, 172–173 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 findings, 4–5, 54, 56 recommendations, 5, 54–56 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 density, xii, 20 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 findings, 4–5, 54, 56 recommendations, 5, 54–56 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 in rural communities, 1, 7 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

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Quality Through Collaboration: The Future of Rural Health 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 defining, 4, 22–23 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

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Quality Through Collaboration: The Future of Rural Health 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

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Quality Through Collaboration: The Future of Rural Health 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 heterogeneity of, 1, 20, 26 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 funding of, 126–139, 141–142 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

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Quality Through Collaboration: The Future of Rural Health 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 challenges facing, 6, 123–124 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 age distribution, 3, 208–210 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 data repository, 7, 75 establishing to measure and improve personal and population health care programs in rural areas, 6–7, 17, 74–75 public reporting, 7, 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 Task Force, 14, 169–170 Rural training tracks and fellowships, developing, 10, 112 Rural/Underserved Opportunities program, 94 Rural-urban continuum code classifications, 206 Rural Utilities Service, 170

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Quality Through Collaboration: The Future of Rural Health 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 Titles VII and VIII, 8, 110 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

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Quality Through Collaboration: The Future of Rural Health 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 remoteness from, 1, 20 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 Wakefield, Mary, ix–x, 193 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

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