Opinions of rural physicians about their practices,community medical needs,and rural medical care.

In a study in the State of Washington during 1971-73, 41 general practitioners in rural areas were asked their opinions about (a) their present practices, (b) the medical care needs of their communities, and (c) rural medical care in general. The most frequently mentioned enjoyable aspects of their practices were the variety and challange of medical problems confronted, the favorable working conditions of the practices, and the types of communities in which the practices were located. The most frequently mentioned sources of frustration to the physicians were the "excess work, responsibility, demands and expectations by patients and community." The physicians were more reluctant to criticize the care received by the residents of their communities than they were to criticize the care that patients received in other rural areas. Suggestions made by the physicians for improving medical care in rural Washington focused on ways to increase the number of resources used to produce medical care, rather than on structural changes in the way medical care is organized, delivered, and financed.     

Primary care program improves reimbursement. The Federally Qualified Health Center program helps hospitals improve services to the medically indigent

Under a program created by Congress in 1989, certain primary care treatment centers serving the medically and economically indigent can become Federally Qualified Health Centers (FQHCs). Recently enacted rules and regulations allow participants in the FQHC program to receive 100 percent reasonable cost reimbursement for Medicaid services and 80 percent for Medicare services. An all-inclusive annual cost report is the basis for determining reimbursement rates. The report factors in such expenses as physician and other healthcare and professional salaries and benefits, medical supplies, certain equipment depreciation, and overhead for facility and administrative costs. Both Medicaid and Medicare reimbursement is based on an encounter rate, and states employ various methodologies to determine the reimbursement level. In Illinois, for example, typical reimbursement for a qualified encounter ranges from $70 to $88. To obtain FQHC status, an organization must demonstrate community need, deliver the appropriate range of healthcare services, satisfy management and finance requirements, and function under a community-based governing board. In addition, an FQHC must provide primary healthcare by physicians and (where appropriate) midlevel practitioners; it must also offer its community diagnostic laboratory and x-ray services, preventive healthcare and dental care, case management, pharmacy services, and arrangements for emergency services. Because FQHCs must be freestanding facilities, establishing them can trigger a number of ancillary legal issues, such as those involved in forming a new corporation, complying with not-for-profit corporation regulations, applying for tax-exempt status, and applying for various property and sales tax exemptions. Hospitals that establish FQHCs must also be prepared to relinquish direct control over the delivery of primary care services.     

Cancer information needs in rural areas

Although cancer presents obstacles for all who experience it, persons in rural communities must negotiate additional challenges. This study determined the cancer information (CI) needs and the CI-seeking behavior and preferences among rural-dwelling persons. Patients (N = 801) = 50 years of age seen in 36 rural Kansas primary care practices completed a Cancer Care Information Needs Survey (CCINS); physicians completed a cancer resource knowledge and preference survey. Of the 801 patients, 184 (23%) reported a CI need. Of these 184 patients, 45% reported either not discussing cancer or having insufficient discussion time with their physicians; 44% needed more information after consulting their physician. Patients more likely to report a CI need were young, female, Internet users, persons with a prior cancer diagnosis, and persons seeing male physicians or physicians in group/multispecialty practices. Patients and physicians were unfamiliar with services provided by national cancer organizations. Physicians are a primary CI source; however, patients who need CI report insufficient cancer discussion time with their physician and need more CI after consulting their physician. Promoting access to national CI sources could bridge the CI needs gap that exists in rural areas currently.     

社区卫生服务培训需求评价

目的：研究社区卫生服务培训需求，方法：深入访谈与问卷调查相结合。共走访了成都和攀枝花市的卫生管理干部和社区医生18人，了解社区卫生服务开展状况，用分层定额抽样的方法抽取了3个成都市的社区，入户调查居民1041人，了解其卫生服务需求和利用情况，以及对社区卫生服务的态度。结果：社区卫生服务内容以常见病的诊疗为主，预防保健，计划生育等服务较少，且缺乏协调，社区卫生服务模式多样，社区医生与服务对象的关系及服务方式正在发生转变，社区医生未能完全适应此转变，医院对社区卫生服务的认识存在误区，社区卫生服务缺乏有效的激励机制，多数居民尚未能接受目前的社区卫生服务。结论：社区卫生服务培训应与社区卫生工作者的实践相结合，社区卫生服务培训应区阶段，分层次，有目的，有针对性地开展，培训对象应包括：管理干部，师资，社区医生和社区护士。     

Shaping the future of academic health centers: the potential contributions of departments of family medicine

Academic health centers (AHCs) must change dramatically to meet the changing needs of patients and society, but how to do this remains unclear. The purpose of this supplement is to describe ways in which departments of family medicine can play leadership roles in helping AHCs evolve. This overview provides background for case studies and commentaries about the contribution of departments of family medicine in 5 areas: (1) ambulatory and primary care, (2) indigent care, (3) education in community and international settings, (4) workforce policy and practice, and (5) translational research. The common theme is a revitalization of the relationship between AHCs and the communities they serve across all missions. Family medicine leadership can provide dramatic organizational improvement in primary and ambulatory care networks and foster opportunities for leadership by AHCs in improving the health of the population. Departments of family medicine can also play a leading role in developing new partnerships with community-based organizations, managing the care of the indigent, and developing new curricula in community and international settings. Finally, family medicine departments and their faculty have a central role in helping AHCs respond to workforce needs and in developing translational research that emphasizes the health of the population and effectiveness of care. AHCs are a public good that must now evolve substantially to meet the needs of patients and society. By pushing for substantial change, by helping to reinvigorate the relationship between AHCs and the communities they serve, and by emphasizing fundamental innovation in clinical care, teaching, and research, family medicine can help lead the renewal of the AHC.     

Entrance and Exit of Obstetrics Providers in Rural Alabama

In Alabama between 1985 and 1989, a total of 94 physicians outside of the four largest cities in the state dropped the obstetrics portion of their practices or left practice in their communities altogether. During the same period 82 physicians entered obstetrics practice in this area. The study presented here used survey and archival data to compare practice characteristics of generalists and specialists in rural and town counties who made different decisions about providing obstetrics care. More generalists left and more specialists entered practice both in town and in rural counties. Rural counties lost more obstetrics providers because more generalists provided the obstetrics care in these areas. Across both specialty and county categories, physicians in group practice who accepted Medicaid and had local access to larger numbers of patients were more likely to remain or begin new obstetric practices. During this period, some obstetrics specialists moved into rural communities that had previously supported only generalist physicians. These findings suggest that the options for organizing successful obstetrics practices have narrowed, putting solo and generalist physicians who operate small-scale obstetrics practices at a disadvantage. These physicians also face competition from obstetrics specialists who are beginning to enter practice in the rural areas of the state. Designing policies that effectively improve geographic access to care requires a realistic understanding of the practice constraints faced by obstetrics providers. For example, as centralized specialist group practices serve residents from surrounding rural areas, programs that facilitate linkages, such as satellite clinics and use of mid-level practitioners, can be promoted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cancer Information Needs in Rural Areas

ABSTRACT

Although cancer presents obstacles for all who experience it, persons in rural communities must negotiate additional challenges. This study determined the cancer information (CI) needs and the CI-seeking behavior and preferences among rural-dwelling persons. Patients (N = 801) ≥ 50 years of age seen in 36 rural Kansas primary care practices completed a Cancer Care Information Needs Survey (CCINS); physicians completed a cancer resource knowledge and preference survey. Of the 801 patients, 184 (23%) reported a CI need. Of these 184 patients, 45% reported either not discussing cancer or having insufficient discussion time with their physicians; 44% needed more information after consulting their physician. Patients more likely to report a CI need were young, female, Internet users, persons with a prior cancer diagnosis, and persons seeing male physicians or physicians in group/multispecialty practices. Patients and physicians were unfamiliar with services provided by national cancer organizations. Physicians are a primary CI source; however, patients who need CI report insufficient cancer discussion time with their physician and need more CI after consulting their physician. Promoting access to national CI sources could bridge the CI needs gap that exists in rural areas currently.     

Surviving in rural America. Providers must adapt to the changing healthcare environment

As the rural healthcare environment changes, the abilities to assess the situation quickly and to implement decisions under conditions of uncertainty are crucial success factors. Rural healthcare providers and rural communities must examine certain assumptions underlying the delivery of healthcare services in rural areas, including the following: The rural renaissance of the 1970s will return. Rural communities need and want hospitals. Local physicians are the backbone of rural healthcare delivery. Transportation is a major barrier to healthcare service delivery. Competition in the delivery of healthcare services is appropriate for rural areas. The questionable validity of these assumptions implies that the current infrastructures for delivering rural healthcare services may no longer be appropriate. To adapt to changes, providers must (1) ensure changes fit with local conditions, (2) consider regionalization, (3) integrate all human services, not just health services, into a cooperative arrangement, (4) consider alternative configurations for providing physician services, and (5) place greater emphasis on transportation and telecommunication systems as means for ensuring timely access.     

The value of collaboration in eliminating barriers to preventive care and screening among underserved populations

Collaboration among a community's institutions and its residents can help increase the use of appropriate screening, preventive, and primary care services. To improve the health of the community, institutions must reach out to their colleagues and other stakeholders. They must not only deal with the structure of the healthcare delivery system but also be responsive to the characteristics of the local population groups they are trying to serve. Over the last several years, a group of 25 community-based partnerships across the country have used a multifaceted model to guide their work in making their communities healthier. Through a wide variety of initiatives tailored to local needs, they have not only improved people's health but also provided a series of benefits to the partnering organizations and the community as a whole.     

A regional strategy. Networking gives rural residents access to high-quality healthcare

In 1978 the Board of Trustees at St. Edward Mercy Medical Center, Fort Smith, AR, adopted a policy that the center would increase its bed size only to meet community needs or to offer needed services. The policy choice was the first step in the development of a regional network that now serves five rural communities. Although there was some resistance to the move at first, when management formalized some of its basic assumptions and values, it became clear that establishing a regional network was right for St. Edward. It would provide economic benefits to the communities in which facilities were acquired or constructed; it would give rural residents better access to primary healthcare; and it would provide the Religious Sisters of Mercy an opportunity to extend their ministry. Networking has also allowed the facilities involved to develop economies of scale and to avoid costly duplication of certain basic services. In addition, primary care physicians in rural communities served by the network have been an important source of referrals to specialists who utilize St. Edward.     

Rural system addresses social, economic needs. Cooperation, education, and advocacy revitalize a region's healthcare delivery

In recent years leaders at Presentation Health System (PHS), Sioux Falls, SD, have expanded their mission to help strengthen local communities economically and socially. PHS now offers support to rural leaders in business, politics, and healthcare through its Center for Rural Health and Economic Development. In addition, educational outreach coordinators have created programs that address the needs of the entire rural community. To establish an effective network of services in the region, two of the system's tertiary care hospitals are collaborating to provide emergency helicopter service. These larger facilities also extend outreach services to rural hospitals and clinics. PHS assists rural hospitals in grant writing and in adapting to changing government reimbursement rules. In addition, the healthcare system coordinates a group purchasing program and a debt collection agency. An important voice for its region's healthcare needs, PHS has worked with the state of South Dakota to address problems and concerns about emergency medical services. The system also publishes Report, a quarterly newsletter that keeps rural residents abreast of healthcare issues affecting them. Two years ago, PHS's Center for Rural Health and Economic Development sponsored its first Invitational Rural Health Leadership Conference. These annual conferences bring together leaders to examine ways to improve rural healthcare delivery by strengthening the social and economic fabric of rural communities.     

Educational and health services innovation to improve care for rural Hispanic communities in the USA

BACKGROUND: Access to comprehensive and quality healthcare services is difficult for socioeonomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina, USA, is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations, in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural healthcare initiatives targeting minority groups. This article reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.     

Orthopedic surgery in rural American hospitals: a survey of rural hospital administrators

Rural American residents prefer to receive their medical care locally. Lack of specific medical services in the local community necessitates travel to a larger center which is less favorable. This study was done to identify how rural hospitals choose to provide orthopedic surgical services to their communities. Methods: All hospitals in 5 states located in communities that met the criteria for a rural town according to the Rural Urban Commuting Area codes were included. A survey with topics including community and hospital demographics, orthopedic surgical workforce and demand, surgical services, and the perceived benefit of orthopedic services was sent to the hospital administrators. Results: Of the 223 rural hospitals surveyed, 145 completed the survey. Of those completing the survey, 30% had at least one full‐time orthopedic surgeon, 25% did not provide any orthopedic surgical services, 65% never had an orthopedic surgeon on ER call, 33% were recruiting an orthopedic surgeon, 52% stated that it is more difficult to recruit an orthopedic surgeon vs a general surgeon, and 71% of the administrators acknowledged a need for additional orthopedic surgical services in their community. For those hospitals that did not have a full‐time orthopedic surgeon, members of those communities traveled a mean distance of 55 miles for emergency orthopedic surgical care as reported by the hospital administrators. Conclusions: There are many rural communities that have limited access to orthopedic surgical services. While many of the rural hospital administrators feel that there is a need for additional orthopedic surgical services in their communities, it is difficult to recruit orthopedic surgeons to these areas.     

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.     

Use of complementary and alternative healthcare practices among persons served by a remote area medical clinic

Remote rural communities are often without adequate healthcare resources. To address the need in one area of Appalachia, an annual medical clinic is held to provide free healthcare services to residents of Appalachia. The Appalachian culture has a number of unique features that influence the healthcare practices of persons living in this region. Cultural values and beliefs about health and the use of complementary and alternative therapies among those attending the remote rural clinic are described, with faith healing, including prayer, and family-taught remedies being the most commonly used complementary and alternative medicine modalities.     

Partnerships for the future. A new vision for the Catholic healthcare ministry

Collaboration among healthcare providers will help them more effectively meet the needs of their communities in the 1990s. San Francisco-based Catholic Healthcare West (CHW), formed in 1986, strives to provide high-quality healthcare by collaborating with Catholic and non-Catholic providers. CHW leaders believe that Catholic providers make ideal partners; however, they have found that Catholic healthcare providers often must look outside the Catholic healthcare ministry to find these partnership opportunities in order to remain viable and effectively carry out their mission. Besides system-to-system or hospital-to-hospital linkages, collaboration is also achievable with other types of healthcare providers, such as physicians. In collaborations between Catholic and non-Catholic healthcare providers, Catholic providers must strive to maintain their Catholic identity. When evaluating potential partners, they must consider issues such as corporate culture, organizational compatibility, and sponsor influence. CHW leaders believe that for any merger or affiliation to be successful, it must clearly produce market and financial advantages for the new partnership and offer the community a significant improvement in quality of care and services.     

Grandmothers as gatekeepers? The role of grandmothers in influencing health-seeking for mothers and newborns in rural northern Ghana

Previous research suggests that care-seeking in rural northern Ghana is often governed by a woman's husband or compound head. This study was designed to explore the role grandmothers (typically a woman's mother-in-law) play in influencing maternal and newborn healthcare decisions. In-depth interviews were conducted with 35 mothers of newborns, 8 traditional birth attendants and local healers, 16 community leaders and 13 healthcare practitioners. An additional 18 focus groups were conducted with stakeholders such as household heads, compound leaders and grandmothers. In this region, grandmothers play many roles. They may act as primary support providers to pregnant mothers, care for newborns following delivery, preserve cultural traditions and serve as repositories of knowledge on local medicine. Grandmothers may also serve as gatekeepers for health-seeking behaviour, especially with regard to their daughters and daughters-in-law. This research also sheds light on the potential gap between health education campaigns that target mothers as autonomous decision-makers, and the reality of a more collectivist community structure in which mothers rarely make such decisions without the support of other community members.     

Physician extenders increase healthcare access

To ensure rural residents access to primary care services, Saint Vincent Hospital and Health Center, Billings, MT, operates five physician-operated clinics, located between 8 and 81 miles from Billings. Two of the clinics are in communities that are not large enough to sustain a physician practice, so they are staffed by certified physician assistants (PA-Cs). Licensed and practicing with supervision of a physician, PAs provide a variety of patient care services in virtually every medical specialty and environment. One-third of the nation's PAs work in primary care health professional shortage areas, providing services comparable to those of a family practitioner. National studies reveal a high degree of satisfaction among both consumers and supervising physicians regarding the level of care provided by PAs. Professional liability claims against PAs are fewer than those against physicians, probably because of the higher degree of communication and attention patients receive as a result of the team approach. PAs can increase patient contact hours, decrease waiting times, and improve access to care overall. In addition, PA utilization is a cost-effective approach to healthcare delivery.     

Positioning doctors for convenience medicine

Faced with an increasingly competitive environment, physicians must learn to organize themselves into group practices positioned to perform as the customer expects. To be successful, these new group practices must recruit the kind of physician who will meet the consumer's demands for quality care: convenience, continuity of care, and confidence in the doctor's competence. This article describes how doctors can become more competitive based on my observations as a former consultant with such healthcare companies as Cigna Healthplan, the largest for-profit HMO, and as the current vice president of Operations Planning and Development with Republic Health Corporation, a Dallas-based hospital management company. These observations should help hospital managers learn how to organize their medical staffs to better serve the patient's needs. By repositioning their physician services, hospitals should become better positioned to compete for new patients.