Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study.

STUDY OBJECTIVE: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

The Business Case for Tele-emergency.

BACKGROUND: Tele-emergency is an expanding telehealth service that provides real-time audio/visual consultation delivered by an emergency medicine team to a remote, often rural, emergency department (ED). Financial analyses of tele-emergency in the literature are limited. This article expands the tele-emergency literature to describe the business case for tele-emergency. "Business case" is defined as a reasoned argument, supported by objective data and/or qualitative judgment, to implement or continue a service or product. MATERIALS AND METHODS: To evaluate tele-emergency financing from the perspective of a critical access hospital (CAH), 10 financial analysis categories were defined. Telephone interviews, site visits, and financial data from the eEmergency program of Avera Health (Sioux Falls, SD) were used to populate the categories. Avera Health information was augmented with national data where available. Three financial scenarios were then analyzed for CAH profit/loss associated with tele-emergency. RESULTS: Tele-emergency financial analysis demonstrated an $187,614 profit in a high revenue/low expense scenario, $49,841 profit in a midrange scenario, and $69,588 loss in a low revenue/high expense scenario. CONCLUSIONS: Tele-emergency may be a profitable rural hospital service line if the participating hospital adjusts ED processes to take advantage of increased revenue/savings opportunities afforded by tele-emergency. Savings due to tele-emergency primarily accrue when physician ED backup and physician ED staffing costs are substituted.

Factors Affecting Staff Perceptions of Tele-ICU Service in Rural Hospitals.

INTRODUCTION: Telemedicine is designed to increase access to specialist care, especially in settings distant from tertiary-care centers. One of the more established telemedicine applications in hospitals is the tele-intensive care unit (tele-ICU). Perceptions of tele-ICU users are not well studied. Thus, we undertook a study focused on assessing staff acceptance at multiple hospitals that had implemented a tele-ICU system. MATERIALS AND METHODS: We designed a survey instrument that gathered perceptions on multiple facets of tele-ICU use and administered it to clinical and administrative staff at 28 hospitals that had implemented a tele-ICU system. We also conducted interviews at half of these hospitals to gain a deeper understanding of factors affecting staff perceptions of tele-ICU services. RESULTS: The 145 survey respondents were generally positive about all facets of the service. Analyses found no significant differences in comparisons between critical access and larger hospitals or between clinical and administrative/managerial respondents, although a few differences between providers and nurses emerged. Respondents at hospitals averaging more tele-ICU use and that had implemented it longer were significantly (p<0.05) more positive in their responses on multiple survey items than other respondents. Interviews corroborated and provided insight into survey responses. CONCLUSIONS: Tele-ICU was particularly valued when critical access hospitals retained critical care patients during special circumstances and when the tele-ICU hub could monitor patients to provide relief for local providers and nurses. Tele-ICU can aid rural hospitals, but multiple delivery models are warranted to meet disparate needs.

Effect of tele-emergency services on recruitment and retention of US rural physicians.

INTRODUCTION: As competition for physicians intensifies in the USA, rural areas are at a disadvantage due to challenges unique to rural medical practice. Telemedicine improves access to care not otherwise available in rural settings. Previous studies have found that telemedicine also has positive effects on the work environment, suggesting that telemedicine may improve rural physician recruitment and retention, although few have specifically examined this. METHODS: Using a mixed-method approach, clients of a single telemedicine service in the Upper Midwestern USA were surveyed and interviewed about their views of the impact of tele-emergency on physician recruitment and retention and the work environment. Surveys were completed by 292 clinical and administrative staff at 71 hospitals and semi-structured interviews were conducted with clinicians and administrators at 16 hospitals. RESULTS: Survey respondents agreed that tele-emergency had a positive effect on physician recruitment and retention and related workplace factors. Interviewees elucidated how the presence of tele-emergency played an important role in enhancing physician confidence, providing educational opportunities, easing burden, and supplementing care, workplace factors that interviewees believed would impact recruitment and retention. However, gains were limited by hospitals' interpretation of the Emergency Medical Treatment and Labor Act as requiring on-site physician coverage even if tele-emergency was used. CONCLUSIONS: Results indicate that, all other factors being equal, tele-emergency increases the likelihood of physicians entering and remaining in rural practice. New regulatory guidance by the Centers for Medicare and Medicaid Services related to on-site physician coverage will likely accelerate implementation of tele-emergency services in rural hospitals. Telemedicine may prove to be an increasingly valuable recruitment and retention tool for rural hospitals as competition for physicians intensifies.

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program.

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.

Nursing home closures and access to post-acute care and long-term care services in rural areas.

PURPOSE: Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. METHODS: We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. FINDINGS: Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. CONCLUSIONS: Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability.

PURPOSE: Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated. METHODS: We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use. FINDINGS: Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38). CONCLUSIONS: Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.

Medicare accountable care organization characteristics associated with participation in 2-sided risk.

PURPOSE: To examine the associations of accountable care organization (ACO) characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (SSP). METHODS: CMS ACO Public Use Files and Provider-Level Research Identifiable Files were used to trace Medicare ACOs' participation in the SSP between 2012 and 2020 and measure ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance. Logistic regression and survival analysis were used to test the associations between ACO characteristics and the probability of ACOs initially participating in or subsequently switching to 2-sided risk tracks. FINDINGS: Among the 624 Medicare SSP ACOs that started between 2012 and 2017, 26 participated in 2-sided risk tracks in their initial contracts and 95 switched to 2-sided risk tracks subsequently. ACO characteristics were not significantly associated with the probability of participating in 2-sided risk tracks in initial contracts. ACO size, affiliation with supporting organizations, and performance were positively associated with the likelihood of switching to 2-sided risk. Rural ACOs were less likely to switch to 2-sided risk than their urban counterparts. CONCLUSIONS: Small and rural ACOs are less prepared to transition into 2-sided risk swiftly.

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis.

OBJECTIVE: To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance. DATA SOURCES: Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. STUDY DESIGN: We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. DATA COLLECTION/EXTRACTION METHODS: Secondary data linked at the hospital level. PRINCIPAL FINDINGS: Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. CONCLUSIONS: MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

Beyond patient care: a qualitative study of rural hospitals' role in improving community health.

OBJECTIVES: Rural population face more health disadvantages than those living in urban and suburban areas. In rural communities, hospitals are frequently the primary organisation with the resources and capabilities to address health issues. This characteristic highlights their potential to be a partner and leader for community health initiatives. This study aims to understand rural hospitals' motivations to engage in community health improvement efforts and examine their strategies to address community health issues. DESIGN: Eleven semistructured interviews were conducted with key leaders from four rural hospitals in a US Midwestern state. On-site and telephone interviews were audio-recorded and transcribed. The combination of inductive and deductive qualitative analysis was applied to identify common themes and categories. SETTINGS: Participating hospitals are located in US rural counties that have demonstrated progress in creating healthier communities. RESULTS: Three types of motivation drive rural hospitals' community health improvement efforts: internal values, economic conditions and social responsibilities. Three categories of strategies to address community health issues were identified: building capacity, building relationships and building programmes. CONCLUSIONS: Despite the challenges, rural hospitals can successfully conduct community-oriented programmes. The finds extend the literature on how rural hospitals may strategise to improve rural health by engaging their communities and conduct activities beyond patient care.

Cannabis and End-of-Life Care: A Snapshot of Hospice Planning and Experiences Among Illinois Medical Cannabis Patients With A Terminal Diagnosis.

INTRODUCTION: Between 2013 and 2019, Illinois limited cannabis access to certified patients enrolled in the Illinois Medical Cannabis Program (IMCP). In 2016, the state instituted a fast-track pathway for terminal patients. The benefits of medicinal cannabis (MC) have clear implications for patients near end-of-life (EOL). However, little is known about how terminal patients engage medical cannabis relative to supportive care. METHODS: Anonymous cross-sectional survey data were collected from 342 terminal patients who were already enrolled in (n = 19) or planning to enroll (n = 323) in hospice for EOL care. Logistic regression models compare patients in the sample on hospice planning vs. hospice enrollment, use of palliative care vs. hospice care, and use standard care vs non-hospice palliative care. RESULTS: In our sample, cancer patients (OR = 0.21 (0.11), p < .01), and those who used the fast-track application into the IMCP (OR = 0.11 (0.06), p < .001) were less likely to be enrolled in hospice. Compared to patients in palliative care, hospice patients were less likely to report cancer as their qualifying condition (OR = 0.16 (0.11), p < .01), or entered the IMCP via the fast-track (OR = 0.23 (0.15), p < .05). DISCUSSION: Given low hospice enrollment in a fairly large EOL sample, cannabis use may operate as an alternative to supportive forms of care like hospice and palliation. Clinicians should initiate conversations about cannabis use with their patients while also engaging EOL Care planning discussions as an essential part of the general care plan.

Patient Aligned Care Team (PACT) Performance in Urban and Rural VHA Primary Care Clinics: A Mixed Methods Study.

PURPOSE: To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA). METHODS: An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process-oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same-day access; continuity with primary care provider; and postdischarge follow-up. Qualitative data collected during on-site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics. FINDINGS: After adjusting for patient- and practice-level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow-up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high-speed Internet were also reported as barriers. CONCLUSIONS: This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient-centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study).

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Inpatient hospital service utilization of the uninsured in Nebraska: policy implications for addressing uncompensated care.

In order better to inform policymakers about financing uncompensated hospital care through appropriate allocation of resources among Nebraska communities, this study used seven years (1996-2002) of county-level data from multiple sources to examine the relationship between population economic factors and the hospital inpatient care use by uninsured patients. The generalized estimating equation (GEE) regression analysis showed that, at the county level, the population uninsurance rate and other economic factors (e.g., per capita income, the percentage of population receiving welfare) are statistically significant predictors of average hospital self-pay inpatient charge per resident. Residents in the three western regions of the state also incurred statistically higher per-resident hospital self-pay inpatient charges than did their counterparts in the three eastern regions. State policymakers in Nebraska can use our study results to allocate resources on the basis of community economic characteristics and geographic location, to help reduce the financial burden of caring for the uninsured to safety net hospitals. The study may have a wide application to other states examining the same policy issues. The model used in this study can be easily created for other states, as the required data are readily available.

The magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions.

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated $9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the population's economic status and primary care physician supply-residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Do rural hospitals lag behind urban hospitals in addressing community health needs? An analysis of recent trends in US community hospitals.

OBJECTIVE: This study examined whether rural and urban hospitals differ in their level of responsiveness to community health needs. DESIGN: This study used a multivariate, longitudinal research design. RESEARCH SETTING: A cross-sectional survey was the setting for this study. PARTICIPANTS: The participants were rural or urban hospitals in the United States. MAIN OUTCOME MEASURES: The dependent variables were selected from the American Hospital Association hospital survey questions that are related to community health needs. The independent variable was rural or urban location. RESULTS: Rural hospitals improved more than urban hospitals in addressing community health needs from 1997 through 2006 for most of the indicators, especially in working with other providers to conduct a community health assessment. However, rural hospitals still lag significantly behind urban hospitals in tracking health information. CONCLUSIONS: This study suggests that rural hospitals do not lag behind urban hospitals in addressing community health needs. Further research is needed to understand the role of community hospitals in influencing local health delivery system activities regarding the potential community benefits and their impact on improving health of local populations.

Continuing effects of Medicare Part D on rural independent pharmacies who are the sole retail provider in their community.

BACKGROUND: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established funding to allow Medicare beneficiaries to enroll in plans providing outpatient prescription drug coverage beginning in January 2006. The Medicare Part D program has changed the means by which beneficiaries purchase prescription drugs, impacting the business operations of pharmacies. OBJECTIVES: To describe the experiences of rural independently owned pharmacies that are the sole retail pharmacy in their community 1 year after implementation of Medicare Part D, in order to learn if the initial financial and administrative problems associated with the implementation of the program in 2006 resolved over time. METHODS: A semistructured interview protocol was used in telephone interviews with 51 pharmacist owners of rural sole community pharmacies in 27 states who were identified through a random sampling process. RESULTS: The sole community pharmacists interviewed continue to face challenges directly related to Medicare Part D. Dealing with Part D plans and working with patients during enrollment periods remains administratively burdensome. Reimbursement amounts, complexity of dealing with multiple plans, and timeliness of payments continue to be cited as problems which could threaten the viability of independently owned pharmacies who are the sole retail providers in their communities. CONCLUSIONS: Actions should be considered to help sole community pharmacies deal with the ongoing administrative and financial challenges of Part D. To ensure full choice for rural Medicare beneficiaries and full access to pharmaceuticals through the ongoing presence of a local pharmacy, the development of a mechanism to structure prescription reimbursement so that drug acquisition costs and related overhead are covered and a reasonable profit margin provided should be considered. Further study is needed to determine how existing policies and regulations can be modified to ensure reasonable access to pharmacy services for rural Medicare and Medicaid beneficiaries.

Comparing Rural and Urban Medicare Advantage Beneficiary Characteristics.

Purpose: The Medicare Advantage (MA) program allows Medicare beneficiaries to receive benefits from private plans rather than from traditional fee-for-service (FFS) Medicare. Little is known about the rural and urban differences in the populations that enroll in the MA program, and these differences may be important for setting policy. This brief uses data from the 2012-13 Medicare Current Beneficiary Survey (MCBS) to describe these differences, and combined with county-level data on MA issuer participation, this dataset also allows us to assess the degree to which issuers may engage in selective MA market entry on the basis of demographic characteristics. Key Findings: (1) Rural and urban MA and FFS populations did not differ much on average by any characteristics reported in the data, including age, self-reported health status, cancer diagnosis, smoking status, Medicaid status, or by other variables assessing frailty and presence of chronic conditions. (2) Most measures of access were similar across rural and urban respondents. However, in terms of cost, urban enrollees were less likely to pay an additional premium (beyond Medicare Part A and B) to obtain MA coverage: 42 percent reported doing so in urban places, while 54 percent did so in rural places. (3) While rurality on its own was often a significant predictor of lower issuer participation in a county's MA market, the addition of other demographic characteristics did not influence the prediction. In other words, we found no evidence, based upon MCBS data, that issuers exclude rural counties due to other demographics.

Mobilising cross-sector collaborations to improve population health in US rural communities: a qualitative study.

OBJECTIVES: This study examines types and forms of cross-sector collaborations employed by rural communities to address community health issues and identifies factors facilitating or inhibiting such collaborations. SETTING: We conducted case studies of four rural communities in the US state of Iowa that have demonstrated progress in creating healthier communities. PARTICIPANTS: Key informants from local public health departments, hospitals and other health-promoting organisations and groups participated in this study. Twenty-two key-informant interviews were conducted. Participants were selected based on their organisation's involvement in community health initiatives. RESULTS: Rural communities used different forms of collaborations, including cross-sector partnership, cross-sector interaction and cross-sector exploration, to address community health issues. Stakeholders from public health, healthcare, social services, education and business sectors were involved. Factors facilitating cross-sector collaborations include health-promoting local contexts, seed initiatives that mobilise communities, hospital visions that embrace broad views of health and shared collaboration leadership and governance. Challenges to developing and sustaining cross-sector collaborations include different institutional logics, financial and human resources constraints and geographic dispersion. CONCLUSIONS: Rural communities use cross-sector collaborations to address community health issues in the forms of interaction and exploration, but real and lasting partnerships are rare. The development, operation and sustainment of cross-sector collaborations are influenced by a set of contextual and practical factors. Practical strategies and policy interventions may be used to enhance cross-sector collaborations in rural communities.

Organizational Attributes Associated With Medicare ACO Quality Performance.

PURPOSE: To evaluate associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance. METHODOLOGY: We conducted cross-sectional and longitudinal analyses of ACO quality performance using data from the Centers for Medicare and Medicaid Services and additional sources. The sample included 322 and 385 MSSP ACOs that had successfully reported quality measures in 2014 and 2015, respectively. RESULTS: Results show that after adjusting for other organizational factors, rural ACOs' average quality score was comparable to that of ACOs serving other geographic categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher posthospitalization follow-up rates achieved better quality performance. CONCLUSION: There is no significant difference in average quality performance between rural ACOs and other ACOs after adjusting for structural and service-provision factors. MSSP ACO quality performance is positively associated with hospital-system sponsorship, beneficiary panel size, and posthospitalization follow-up rate.