Showing papers in "Journal of Rural Health in 1991"

Hospital Choice of Medicare Beneficiaries in a Rural Market: Why Not the Closest?

Abstract: As part of a larger study of hospital choice, the travel patterns of more than 12,000 Medicare beneficiaries residing in three overlapping rural areas were examined. During 1986 these Medicare beneficiaries were admitted to one of 53 hospitals in an area that encompassed parts of Minnesota, North Dakota, and South Dakota. Information on ZIP code of residence, closest hospital, and hospital of admission were used to analyze hospital choices of the Medicare rural elderly residing in this area. To summarize their travel patterns, the admitting hospital was categorized based on whether it was urban or rural, its size and whether or not it was the closest facility. Findings indicated that 60 percent of these rural Medicare beneficiaries used hospital services at their closest rural hospital, regardless of its size. However, 79 percent of those whose closest hospital was larger than 75 beds used it, while only 54 percent of those whose closest rural hospital was fewer than 75 beds obtained services there. Overall, 30 percent of those residing in this rural market area went to an urban hospital. These patterns appeared to reflect an evaluation by the physician and/or individual of the relative attractiveness of the local hospital versus alternatives available, as well as the individual's characteristics. Travel patterns varied by the beneficiary's age as well as his or her relative complexity of illness, as measured by a Disease Staging methodology. Findings have implications for the provision and financing of hospital services in rural areas.

Current approaches to shortage area designation.

Abstract: This paper reviews the various indicators and criteria that are in use to identify rural and urban areas with shortages of primary care physicians, dentists, psychiatrists, or nurses; areas with medically underserved populations; high migrant impact areas; and areas of greatest need/shortage, leading to lists of designated shortage or underserved areas eligible for various federal and state programs; and to lists of areas with priority for resource placement. Presenting these shortage and underservice criteria at a workshop dealing with adequacy was not meant to suggest an equivalency between the concepts of "shortage," "underservice," and "adequacy," but the shortage and underservice criteria can be thought of as a floor on the definition of adequacy, and may contain elements of that definition. Refinements or revisions to the various criteria could probably better identify the needs in rural areas, or the kind of staffing mix needed in various types of areas, or improve priority setting among designated areas; but the existing criteria remain a good first screen to identify those areas with health services-related needs that require further attention.

The use of health service areas for measuring provider availability.

Abstract: Measurement of the availability of health care providers in a geographic area is a useful component in assessing access to health care. One of the problems associated with the county provider-to-population ratio as a measure of availability is that patients frequently travel outside their counties of residence for health care, especially those residing in nonmetropolitan counties. Thus, in measuring the number of providers per capita, it is important that the geographic unit of analysis be a health service area. We have defined health care service areas for the coterminous United States, based on 1988 Medicare data on travel patterns between counties for routine hospital care. We used hierarchical cluster analysis to group counties into 802 service areas. More than one half of the service areas include only nonmetropolitan counties. The service areas vary substantially in the availability of health care resources as measured by physicians and hospital beds per 100,000 population. For almost all of the service areas, the majority of hospital stays by area residents occur within the service area. In contrast/for 39 percent of counties, the majority of hospital stays by county residents occur outside the county. Thus, the service areas area more appropriate georgraphic unit than the county for measuring the availability of health care.

Poverty, Primary Care and Age-Specific Mortality*

Abstract: An important area of concern among rural health researchers and policy analysts is the social and ecological correlates of mortality levels. This research is concerned with the empirical relationship between the prevalence of poverty and the mortality experience of different age groups within the population. Poverty is viewed as a characteristic ofthe social organization of local areas and operationalized by employing several indicators, including a measure of rurality. The empirical results indicate that the magnitude of the association between the prevalence of poverty and mortality varies among different age groups. The impact of rurality, while being consistently positive, is shown to be statistically nonsignificant. The research also shows that the availability of primary care is associated with lower mortality.

Family medicine education and rural health: a response to present and future needs.

Abstract: The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.

Causes and consequences of rural small hospital closures from the perspectives of mayors.

Abstract: Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community's economy.

The economic impact of hospitals in rural communities.

Abstract: This article presents how to assess the economic impact of a hospital on a rural community. The economic impact is identified by assessing the direct, induced, and indirect impacts that result because of the presence of a hospital in a rural community. The methodology utilizes survey data and estimation procedures for four rural hospitals. The economic impact estimates are based on microdata. Income multipliers are estimated for each of the rural communities. The research demonstrates that rural hospitals do make significant economic contributions to the communities they serve. Community leaders can use the model presented to evaluate the economic impact of their local hospital.

Geographic distribution of physician manpower: the GMENAC (Graduate Medical Education National Advisory Committee) legacy.

Abstract: The Graduate Medical Education National Advisory Committee (GMENAC) projected the need for and supply of physicians and other providers, recommended time and access standards for health care services, and developed guidelines for the geographic distribution of physicians Since this study, analysts have given scant attention to national problems of physician geographic distribution The issue deserves additional scrutiny in light of the current continuing problems of underservice in rural areas The emergence of geographic information systems offers a unique opportunity to acquire data on provider distribution and provide a framework for developing and testing redistribution policy

A Multivariate Assessment of the Effects of Residence on Infant Mortality

Abstract: This research examines the relationship between residence and infant mortality. The purpose of the study was to identify the effects of maternal residence on infant mortality, using a multivariate model which included both individual and county-level variables known to be associated with suboptimal birth outcome. Data on all births in Florida during 1987 were drawn from birth and infant death certificates. In addition, information concerning county sociodemographic structure and medical resources were gathered and linked to the individual records. After examining the distributions of selected risk variables across a five-category measure of residence (from most urban to most rural), a logit model was estimated to predict the odds of an infant death associated with maternal residence. At the bivariate level, rural residents were found to have increased odds of an infant death compared to residents of all other residence categories. Second, a logit model was estimated that controlled for the influence of important maternal, infant, and county risk characteristics. The results of this second, more fully specified model indicate that residence did not have an independent direct effect on infant mortality when the influence of the other risk factors was controlled. We conclude that although residence does not influence infant mortality directly, it does influence mortality indirectly through its association with key risk factors. In particular, because population characteristics and medical resources are differentially distributed across rural and urban areas, residence remains an important factor to be considered when predicting health outcomes. The implications of these findings for polcy-makers and health planners, as well as for health services researchers, are also discussed.

Results of an Educational Intervention to Improve the Health Knowledge, Attitudes and Self‐Reported Behaviors of Swine Confinement Workers

Abstract: Swine confinement workers participated in an educational intervention designed to improve knowledge, attitudes, and behaviors related to respiratory disease. The desired changes were (1) improvement in knowledge about recommended gas and dust levels in buildings and benefits of using properly fitted masks; (2) improvement of attitudes about wearing dust masks, taking safety precautions, and inspecting the ventilation and heating systems; and (3) improvement in behaviors such as regular inspection of buildings and wearing an appropriate dust mask or respirator. The health risks of failing to practice these behaviors include chronic bronchitis, occupational asthma, organic dust toxic syndrome, chronic sinusitis, and even death from acute toxicity related to hydrogen sulfide. An intervention group and a nonintervention group of swine confinement workers were assessed at the beginning of the project and one year later to determine changes brought about by an educational intervention. During that year, swine producers in the intervention group were mailed a series of six educational home-study modules and reference materials on confinement topics. Analysis of covariance and categorical repeated measures analysis were used to determine changes over time in the percentage of people who answered correctly in each group. Significant changes in knowledge scores, attitude scores, and reported behavior scores all favored the intervention group. The 14 statistically significant changes in knowledge items were related to dust mask use, manure pit safety, liquid manure agitation, building gas and dust norms, and recommended gas levels. The four attitudinal items that improved significantly concerned the importance of regular cleaning and upkeep, improving health and safety, knowing ways to keep buildings safer, and recognizing the benefits of wearing a dust mask. The four items about self-reported behavior changes included inspecting and servicing of building heaters, measuring building gases, and wearing a mask while working. Thus, important changes in the intervention group occurred in all three targeted areas—knowledge, attitudes, and behaviors. The results lead to three conclusions: the educational materials were effective; swine producers are educable through a low-cost intervention; and educational intervention acan improve many factors related to the safety and health of confinement workers.

Issues Surrounding the Distribution and Utilization of Nurse Nonphysician Providers in Rural America

Abstract: The cost and quality of health care is an ever-increasing concern. Responsible people are looking for logical solutions. One solution is the increased involvement of nurse practitioners and certified nurse midwives in the delivery of health care services to patients. This paper reviews the supply, education, and responsibilities of nurse practitioners and certified nurse midwives, government studies of the need for nonphysician providers, the cost-effectiveness of health care delivered by nurse practitioners and certified nurse midwives, and impediments to practice.

Rural Youth Disability Prevention Project Survey: results from 169 Iowa farm families.

Abstract: Agriculture is now the most hazardous occupation in the United States and it is the only one in which children not only comprise a significant part of the work force, but also live and play at the work site. Annually, 23,500 pediatric agricultural injuries are reported, with nearly 300 fatalities (Rivara, 1985). The Rural Youth Disability Prevention Project was designed to use innovative, community-oriented methods to address the unique problems of child safety in agriculture. Toward this end, a survey instrument was designed to gather data both to assist in program development and to serve as a pretest for the subsequent evaluation. Analysis of these data indicated several issues to target for intervention efforts. One is lack of supervision--more than 40 percent of children who operate equipment do so unsupervised. Approximately 30 percent of children more than 3 years old play alone in work areas, and 80 percent of these children play near machinery in operation. Another issue is operation of farm machinery by very young children--respondents' children began operating equipment at an average age of 12 years. Coupling this with the finding that the parents believe their children are not capable of operating equipment until age 15 exemplifies the most important issue, the disparity between parents' levels of safety knowledge and safety behavior. Using the survey data to increase local involvement, efforts are being directed toward facilitating an ongoing, community-sponsored intervention program to empower farm families to effect their own solutions.

Prolonged travel time to neonatal intensive care unit does not affect content of parental visiting: A controlled prospective study

Abstract: Decreased local obstetric care appears to be increasing the rate of premature births to rural populations. With increased numbers of premature and complicated births in rural populations, understanding the impact of the Neonatal Intensive Care Unit (NICU) environment on the development of parent-child relationships becomes critical. NICU infants appear to be at increased risk for failure to thrive, child abuse, and neglect. Some reports suggest that the frequency of parental visits to the NICU can predict infants likely to be at risk. Because rural parents visiting infants hospitalized in urban centers are likely to visit less often, understanding this possible relationship is critical. In this controlled prospective study, three groups of parents were observed visiting their hospitalized infants: (1) those visiting "in house" while the mother was still hospitalized; (2) those whose visits required one hour or less in travel time; and (3) those whose visits required more than one hour in travel time. Results showed that travel time influenced the frequency of visits, with fewer visits from those living furthest from the NICU. However, those visiting from greater distances stayed with their infants longer so that there was no difference in the total visiting time over a two-week period. Direct observations of the visits by both mothers and fathers showed no differences in the content of parent-child interactions among groups. Thus, visit frequency alone must be viewed cautiously as a potential indicator of failure to bond with a hospitalized infant, especially in settings serving rural populations.

Barriers to the Retention of Registered and Licensed Practical Nurses in Small Rural Hospitals

Abstract: The availability of nursing resources is one of the most critical issues facing health care organizations in the country. The study investigated the potential factors that relate to the desire of registered nurses (RNs) and licensed practical nurses (LPNs) to continue practicing in rural hospitals of North Dakota. All RNs and LPNs who worked in North Dakota hospitals with fewer than 100 beds (490 hospitals) were mailed survey questionnaires. Approximately eight weeks later, responses were received from 291 respondents for an overall return rate of 59 percent. Correlational analyses were used to examine the subjects' responses. A moderate relationship was found among the work-related variables. Overall job satisfaction and performance constraints were the only variables to make significant contributions to the prediction of turnover intention for both RNs and LPNs. Overall job satisfaction accounted for the largest percentage of the variance (R2 = 0.42 and R2 = 0.44) for RNs and LPNs, respectively. Satisfaction with promotion was the only work-related variable to make a significant contribution to the prediction of turnover intention for RNs (R2 = 0.23). Performance constraints, role ambiguity, and shift worked were the only work-related variables contributing to the prediction of turnover for LPNs. These results are discussed in terms of their implications for the management of RNs and LPNs in rural hospitals. Clinical ladders for promotions, the identification of potential performance constraints, and supervisory training are suggested as target areas in which rural hospitals might focus attention for managing turnover in RNs and LPNs.

Surveillance of Agricultural Injuries in Central Wisconsin: Epidemiologic Characteristics*

Abstract: We implemented a hospital-based agricultural injury surveillance System in central Wisconsin in November 1986. The geographic area of the study is heavily agricultural, with a predominance of dairy farmers. This report describes the epidemiologic characteristics of the 913 patients seen during the first two years of the surveillance System. The majority of patients were male (77%), between the ages of 19 and 65 years of age (68.4%), and either the owner/operator of the farm (42.4%), or the spouse of the owner/operator (10.5%). Falls accounted for the greatest number of injuries in children younger than 16 years of age and in those older than age 65, while animals were the most frequent cause of injury in those between the ages of 16 and 65 years. Injuries were most likely to occur in the months of June, July, and August, which together accounted for 37 percent of the total number of injuries. Despite the limitations of the descriptive data derived front surveillance Systems, such information may be useful for determining the magnitude of a health problem and suggesting hypotheses to account for the apparent distribution of disease and injury.

Rural populations and rural physicians: estimates of critical mass ratios, by specialty.

Abstract: As physicians and other providers of health care services see their traditional markets erode, an increasingly important element of any provider location decision is the determination of a population base or "critical mass" that can professionally and financially support a given set of health care services. While the size of a local population is not the sole determinant of success, ultimately an adequate population base to support a given spectrum of services must be defined, and providers increasingly need tools for evaluating opportunities in the new economic market. This is especially true in rural areas. An earlier supply and demand model for estimating the critical mass of population needed to support a physician in any one of 25 specialties and subspecialties in urban and suburban areas is adapted to the rural market. The assumptions inherent in the earlier model are examined and the issue of "critical mass" is examined from a rural health care perspective in this paper.

HMOs and Managed Care: Implications for Rural Physician Manpower Planning*

Abstract: American health care is changing dramatically. Health maintenance organizations (HMOs) and other managed care plans are central to this change. Today, the majority of Americans living in metropolitan areas receive their care from these types of plans. The goal of this article is two-fold. First, it will discuss the potential implications of HMOs and managed care for physician needs and supply in rural regions. Second, it will derive insight into alternative approaches for meeting rural health manpower needs by analyzing HMO staffing patterns. As HMOs and other managed care plans expand, rural physicians, their practices, and their patients will almost certainly be affected. As described in this paper, most of these effects are likely to be positive. The staffing patterns used by HMOs provide an interesting point of comparison for those responsible for rural health manpower planning and resource development. HMOs appear to meet the needs of their enrollees with significantly fewer providers than are available nationally or suggested by the federal standards. Moreover, HMOs make greater use of nonphysician providers such as nurse practitioners and physician assistants.

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

Abstract: Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.

Perspective on Farm Accident Statistics

Abstract: The frequently cited statistics on farm accidents are based on definitions of farms accidents and on sources of data that exclude some events that could be called farm accidents and that represent only some of all the defensible perspectives on health risks in farming. As a contribution to exploring alternative perspectives on farm accident statistics, mailed surveys of 2,016 Iowa farm operators provided information on accidental injuries in their farm operations during the year preceding the survey. The majority of injuries were home treated, and hence were not events that would be reflected in accident statistics based on medical records. The data allow a breakdown by age, thus enabling an estimate of farm accident rates for children, youth, and the elderly, people whose accidents are typically excluded from farm accident statistics. Data are also presented that provide a farm operator's perspective on farm accidents, showing that many farm operators had knowledge about accidents through their own close calls and through their efforts to assist others who had farm accidents. The farm operator's perspective is also reflected in data indicating greater concern about chemical and air quality health risks than about risks from farm machinery and livestock.

Has Medicare been a 'bad deal' for rural hospitals?

Abstract: Understanding the links between Medicare involvement and financial performance in rural hospitals is important for evaluating reimbursement policy under Medicare's prospective payment system (PPS). While simple comparisons between urban and rural hospitals suggest that the latter have lower PPS profit margins on average, there is little multivariate evidence on how Medicare involvement affects financial performance in rural hospitals and whether this relationship differs between rural and urban hospitals. Existing multivariate evidence suggests that Medicare involvement improves PPS profits in both rural and urban hospitals after controlling for other hospital- and market-specific factors. By contrast, the present analysis considers the relationship between Medicare involvement and broader measures of profitability than PPS profits. This provides insight into whether Medicare reimbursement is adequate relative to other forms of third-party payment. The results indicate that Medicare involvement has a markedly different effect on the profitability of rural versus urban hospitals. Greater Medicare involvement is associated with lower patient care profitability in rural hospitals but has a strong positive and significant effect on both patient care and overall (i.e., patient and nonpatient) profitability in urban ones. Medicare involvement is not significantly related to overall profitability in rural hospitals, however, suggesting that these hospitals may be able to mitigate patient care revenue shortfalls from greater Medicare involvement by increasing their nonpatient care revenue sources.

An assessment of rural hospital trustees' health care knowledge base.

Abstract: Rural hospital trustees are usually volunteers who serve important roles in the governance of a hospital and, therefore, in defining health care policy in their communities Because most trustees are not health professionals, their orientation to the hospital and continuing education about the hospital present a special challenge to administrators One hundred and three trustees from 10 rural hospitals in western New York were surveyed to better understand their demographics, their knowledge base regarding the hospital, and their roles as trustees Sixty-six percent of the respondents were male and the average age of the sample was 48 years Trustees had served an average of six years and spent seven hours per month on hospital business Eighty-three percent recalled receiving some orientation Answers about average hospital census, length of stay, payor type, and hospital services were correct less than 50 percent of the time Trustees were aware that recent quality assurance guidelines increased their liability and half believed it was their most important activity We conclude that greater effort should be applied to the orientation and continuing education of hospital trustees Given the significant time commitment already asked of trustees, this education should be woven into the hospital governance routine

Utilizing cooperative extension services to meet rural health needs.

Abstract: Professionals concerned with rural health issues sometimes overlook the possibilities that the Cooperative Extension Services (CES) hold for addressing rural health problems. Joint venturing between health care and CES professionals can help address the growing rural health care concerns associated with cost containment strategies and the federal deficit, as well as the traditional problems associated with the scarcity of health care resources in rural areas. Cooperative extension, a 75-year-old national, community-based system can provide the structural and program delivery capacity to help shape health care delivery in rural areas through community organization and education. The structure and functions of the CES, brief examples of successful CES programs, and some helpful hints provide insights into the potential for successful cooperation and collaboration. This collaboration can represent a cost-effective strategy to address problems in the changing health care climate.

The structure and characteristics of rural hospital consortia.

Abstract: Rural hospital consortia are relatively new organizations that have been developed to help improve the viability of participating hospitals. This paper describes the characteristics of rural hospital consortia in the United States and develops and tests a measurement model of their underlying structure. The measurement model, which characterized consortia structure in terms of degree of member commitment, degree of complexity, scale of operations, and degree of formalization, provided a good fit to the sample data. Most consortia appear to have followed a relatively conservative course that involved the development of programs that had limited sensitivity and financial risk for individual hospitals. This suggests that rural hospital consortia may not become a model for major structural change in the rural health care system. Future research should examine the evolution of rural hospital consortia from an organizational life cycle perspective.

Rural Adolescent Alcohol Use: An Overview*

Abstract: Summary Use and abuse of alcohol by rural adolescents is an important problem for those who care for youth and for the future of rural communities. Alcohol use is common and associated with many of the risk factors identified in previous urban-sampled research. However, there is considerable rural heterogenety, and the specific characteristics of rural families and communities that may predispose certain adolescents to earlier use or problem drinking are not well understood. Identification of these factors are not only critical for the treatment of affected adolescents and their families, but also for the prevention of adolescent problem drinking. While a number of authors have attempted to describe rural adolescent drinking and associated factors, these studies have been limited by sampling only school populations, small samples, use of unstandardized instruments and no long-term follow-up. In the same vein, no investigators have described the impact of population density, farm residence, predominant local industry, or sociocultural characteristics of rural families and communities on adolescent alcohol use and other health compromising behaviors. Thus, prospective longitudinal studies are sorely needed. Even more important, no research exists that explores the effectiveness of treatment or prevention services for rural adolescents. Communities and providers are forced to rely on models developed in urban settings that do not take into account the lack of access to other services, the shortage of trained specialists, and the limited economic resources of rural communities. A focused effort by investigators, research agencies, and local communities will be necessary for these barriers to be overcome.

The WAMI Rural Hospital Project. Part 5: Community perception of local health care services.

Abstract: Rural health care facilities commonly employ community health care surveys as marketing research instruments to assess consumer utilization of and satisfaction with local services. However, there is little information on the use of survey findings as a way to design interventions to enhance consumer satisfaction and hospital viability. A community survey was administered in six Northwest rural communities as part of the Rural Hospital Project (RHP) to identify weaknesses in local health care services, guide remedial activities, act as a catalyst for change, and assess changes in community perceptions following project interventions. Descriptive findings revealed problems typically observed in small rural communities, including relatively low hospital and physician market share, outmigration for certain types of health care not available locally, and dissatisfaction with some aspects of hospital and physician services. Satisfaction with various aspects of care tended to be lower among males, the uninsured, and younger respondents. Comparisons of survey responses before (1985) and after (1989) the RHP generally demonstrated stability in hospital and physician market share, with project hospitals performing well in 1989 in comparison to other rural hospitals of similar size. The percentage of respondents who rated overall quality of local hospital and physician care positively generally increased or remained stable over the study period. Substantial decreases in satisfaction levels were found for access to care. Importantly, gains were made in those areas and services which received particular emphasis in the project.

The WAMI Rural Hospital Project. Part 6: Overview and conclusions.

Abstract: The Rural Hospital Project (RHP) appeared to make a meaningful difference in the six Northwest rural communities that participated in this integrated community development and strategic planning effort. Although the methodological approach used in the evaluation precludes us from attributing observed changes in outcomes solely to the project interventions themselves, several elements of the process appear to be useful in stabilizing or expanding local health care systems. These include: (1) the involvement of outside organizations in fostering community change, (2) a high degree of community commitment and investment in all stages of the process, (3) comprehensive identification of problems in the health care system by outside consultants, (4) the use of periodic meetings of communities confronting similar issues, (5) identification and development of local leadership, (6) enhancing teamwork among local health care providers, and (7) the development of conflict-resolution mechanisms within health care organizations. Future attempts to use this strategy to strengthen rural health care systems can be enhanced by broadening the range of participation in health services planning, enlisting involvement of medical staff throughout the strategic planning cycle, addressing the issue of physician recruitment, and clarifying responsibility for implementation of community plans. Rural communities will predictably need to identify and resolve a set of core issues. To the extent that external organizations such as medical schools can strengthen the ability of rural health professionals and community leaders to identify and address these issues, the quality and viability of rural health care systems will be enhanced.

The WAMI Rural Hospital Project. Part 1: Historical and theoretical underpinnings.

Abstract: This set of six manuscripts describes the content and impact of the WAMI Rural Hospital Project (RHP), a research and development effort supported by the W.K. Kellogg Foundation, designed to improve the delivery of health services in six rural communities in the Pacific Northwest and Alaska. The major objective of the RHP--an activity which spanned a four-year period from 1985 through 1988--was to assist the project communities in improving the financial stability and quality of care of their local health care systems. Special attention was directed at helping the communities determine and implement an appropriate scope of health services, improve management and governance of the local health care enterprise, recruit and retain additional health personnel, and increase the extent to which community residents used local health services. In this first section we discuss the historical antecedents and conceptual underpinnings of the RHP and describe the five principal phases of the project. These include: (1) selection of communities for participation in the RHP, (2) comprehensive analysis of the health care system in each community, (3) community health services planning, including the development of comprehensive strategic plans, (4) implementation of techniques to improve local health services, and (5) project dissemination and evaluation. A pre-test, post-test model was employed to assess qualitative and quantitative changes in a variety of key measures of health system performance, including organization and management, scope of services, fiscal viability of the rural hospital, and utilization and patient satisfaction with health services in each community. The results of this evaluation constitute the balance of this report.

Future Trends in Nursing Practice and Technology

Abstract: Rural hospitals will be affected by changes in nursing anticipated in the future. Welcome changes will be the maturity and life experiences new graduates will bring to the work setting, knowledge of computers, and a broadening database. New graduates will also know various methods of care delivery, including case management, and will be able to select the delivery system that best meets the needs of the patients and institution. They will be more autonomous and possess leadership and management skills. With their knowledge of community as well as institutional nursing, they will be able to draw upon the skills of both groups to bring the two areas of nursing into continuity of care for patients. A difficulty ahead for rural hospitals is recruitment of new graduates, the majority of whom will have established families and lives elsewhere. And the practice of developing their own employees for higher levels of nursing will be compounded by the doubling of time necessary to complete nursing programs in the future.