RESUMEN
OBJECTIVES: This study investigated inpatient psychiatric units in small rural hospitals to determine their characteristics, the availability of community-based services after discharge, and the impact of the new Medicare payment system on these units. METHODS: Unit managers in all rural hospitals with fewer than 50 beds that had a psychiatric unit in 2006 (N=74) were surveyed on the telephone. RESULTS: On average these units had ten beds and 230 admissions per year. Medicare was the major payer (median of 84%). Typical staffing includes no more than one staff member from each category: psychiatrist, psychologist, social worker, counselor or therapist, and nurse practitioner. Common diagnoses reported were depression (74% of units), schizophrenia or other psychoses (42% of units), and dementia or Alzheimer's disease (57% of units). CONCLUSIONS: Hospital staff reported little difficulty obtaining postdischarge care, and most staff clinicians provided outpatient services locally. Thus mental health services infrastructure appears better in these communities than in most rural communities, but it may be weakened by recent closures reported by some units, caused, in part, by changes in Medicare reimbursement.
Asunto(s)
Tamaño de las Instituciones de Salud , Hospitales Rurales , Pacientes Internos , Servicio de Psiquiatría en Hospital/organización & administración , Encuestas de Atención de la Salud , Tamaño de las Instituciones de Salud/estadística & datos numéricos , Humanos , Entrevistas como Asunto , Medicare , Trastornos Mentales , Mecanismo de Reembolso , Estados Unidos , Recursos HumanosRESUMEN
CONTEXT: Although research shows higher uninsured rates among rural versus urban individuals, prior studies are limited because they do not examine coverage across entire rural families. PURPOSE: This study uses the Medical Expenditure Panel Survey (MEPS) to compare rural and urban insurance coverage within families, to inform the design of coverage expansions that build on the current rural health insurance system. METHODS: We pooled the 2001 and 2002 MEPS Household Component survey, aggregated to the family level (excluding households with all members 65 and older). We examined (1) differences in urban, rural-adjacent, and rural nonadjacent family insurance coverage, and (2) the characteristics of rural families related to their patterns of coverage. FINDINGS: One out of 3 rural families has at least 1 uninsured member, a rate higher than for urban families-particularly in nonadjacent counties. Yet, three fourths of uninsured rural families have an insured member. For 42% of rural nonadjacent families, this is someone with public coverage (Medicaid/SCHIP or Medicare); urban families are more likely to have private health insurance or a private/public mix. CONCLUSIONS: Strategies to expand family coverage through employers may be less effective among rural nonadjacent than urban families. Instead, expansions of public coverage or tax credits enabling entire families to purchase an individual/self-employment plan would better ensure that rural nonadjacent families achieve full coverage. Subsidies or incentives would need to be generous enough to make coverage affordable for the 52% of uninsured rural nonadjacent families living below 200% of the federal poverty level.
Asunto(s)
Composición Familiar , Pacientes no Asegurados , Población Rural , Adolescente , Adulto , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Estados Unidos , Población UrbanaRESUMEN
CONTEXT: National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue. PURPOSE: This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face. METHODS: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded. KEY FINDINGS: About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment. CONCLUSIONS: The lack of community resources may impact CAHs' ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.
Asunto(s)
Servicios Comunitarios de Salud Mental/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Hospitales Rurales/estadística & datos numéricos , Trastornos Mentales/epidemiología , Adolescente , Adulto , Anciano , Trastornos de Ansiedad , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Trastornos Mentales/clasificación , Persona de Mediana Edad , Trastornos del Humor , Evaluación de Necesidades , Proyectos Piloto , Trastornos Psicóticos , Trastornos Relacionados con Sustancias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: A study was conducted in 2004 to determine if 26 interventions--distributed among nine patient safety areas and as recommended by an expert panel as relevant to rural hospitals--would be validated in terms of relevance and implementability for small and rural facilities. METHODS: The chief executive officers (CEOs) and/or key managers responsible for patient safety activities in a diverse group of 29 small and rural hospitals assessed the potential effectiveness and feasibility of the 26 interventions. Representatives of 25 hospitals participated in structured, follow-up phone discussions. RESULTS: Adverse drug events were the highest-priority area for 14 hospitals, followed by patient falls (selected by 5 hospitals). Some hospitals had already implemented intervention 1 (use at least two patient identifiers) and intervention 6 (read back of verbal orders) and thus ranked them highly, especially for implementability. Intervention 3 (24-hour pharmacist coverage) was ranked low, especially on implementability. Interventions involving health information technology were ranked lower by the hospitals than by the expert panel. DISCUSSION: Safety interventions should reflect the general state of the science of safe practices while incorporating relevant contextual issues unique to rural hospitals. The results have important implications for survey and accreditation activity, and the focus of technical assistance and research efforts.
Asunto(s)
Toma de Decisiones en la Organización , Prioridades en Salud/clasificación , Hospitales Rurales/normas , Errores Médicos/prevención & control , Atención al Paciente/normas , Guías de Práctica Clínica como Asunto , Administración de la Seguridad/normas , Consenso , Estudios de Factibilidad , Investigación sobre Servicios de Salud , Hospitales con menos de 100 Camas , Hospitales Rurales/organización & administración , Humanos , Errores Médicos/clasificación , Atención al Paciente/clasificación , Estados UnidosRESUMEN
CONTEXT: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. PURPOSE: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. METHODS: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. FINDINGS: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. CONCLUSIONS: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.