Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening.

BACKGROUND: Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking. OBJECTIVE: To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening. DESIGN: Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics. PARTICIPANTS: People with SMI newly receiving primary care in North Carolina. INTERVENTIONS: Enhanced primary care that includes features tailored for individuals with SMI. MAIN MEASURES: Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit. KEY RESULTS: Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening. CONCLUSIONS: Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States.

BACKGROUND: Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS: Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION: Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

Training Psychologists for Rural Practice: Exploring Opportunities and Constraints.

PURPOSE: To examine trends in the psychologist workforce and training opportunities, including factors that may influence the decision of clinical psychologists to practice in rural settings. METHODS: We use a mixed-methods approach to examine the psychologist workforce nationally and in North Carolina (NC), including (1) an analysis of the location of programs awarding doctoral degrees; (2) an analysis of the practice, demographic, and educational characteristics of the psychologist workforce; and (3) interviews with directors of doctoral programs in clinical psychology to understand where current graduates are getting jobs and why they may or may not be choosing to practice in rural communities. FINDINGS: Fewer than 1% of programs and institutions awarding doctoral degrees in psychology in the United States are located in rural areas. In NC, approximately 80% of practicing psychologists have out-of-state degrees and about 80% of recent NC graduates are not currently licensed in the state. This juxtaposition undermines the utility of adding more in-state degree programs. While expansion of training programs within rural areas could help alleviate the shortages of mental health providers, adding new degree-granting programs alone will not necessarily increase supply. We discuss complementary recruitment and retention strategies, including greater incentives for rural training and practice as well as training in emerging technologies that don't require providers to be physically located in underserved areas, such as telemedicine. CONCLUSIONS: Increasing the supply of psychologists practicing in rural areas will require a thoughtful, multipronged approach to training this critical part of the behavioral health workforce.

Telehealth In Health Centers: Key Adoption Factors, Barriers, And Opportunities.

Telehealth services have the potential to improve access to care, especially in rural or urban areas with scarce health care resources. Despite the potential benefits, telehealth has not been fully adopted by health centers. This study examined factors associated with and barriers to telehealth use by federally funded health centers. We analyzed data for 2016 from the Uniform Data System using a mixed-methods approach. Our findings suggest that rural location, operational factors, patient demographic characteristics, and reimbursement policies influence health centers' decisions about using telehealth. Cost, reimbursement, and technical issues were described as major barriers. Medicaid reimbursement policies promoting live video and store-and-forward services were associated with a greater likelihood of telehealth adoption. Many health centers were implementing telehealth or exploring its use. Our findings identified areas that policy makers can address to achieve greater telehealth adoption by health centers.