Rural Federally Qualified Health Centers Research Articles

Leadership in federally qualified health centers: examining recruitment and retention in rural Oklahoma.

Healthcare workforce shortages, particularly in rural areas, present a global challenge. The purpose of this study is to explore the leadership dynamics within federally qualified health centers (FQHC) in rural Oklahoma, focusing on recruitment, retention, job satisfaction and development practices. Eighteen managers with five or more years of tenure from Oklahoma FQHCs were interviewed. Leadership's role in influencing job satisfaction, recruitment, retention and development practices was analyzed using a multilevel ecological framework through qualitative content analysis with NVivo. The analysis includes ten key themes including the critical role of leadership in addressing recruitment and retention challenges, the importance of aligning organizational culture, rural culture, access challenges, trainings and values with workforce development initiatives, and the impact of leadership practices on job satisfaction. This study uniquely examines leadership strategies in rural FQHCs, integrating ecological considerations for cultural, logistical and community-specific factors. It emphasizes the pivotal role leadership plays in shaping workforce development. As rural healthcare evolves, refining these approaches is crucial for addressing workforce challenges, improving healthcare access and ensuring that rural FQHCs remain sustainable, driving positive outcomes for healthcare professionals and communities.

Evaluating the Effectiveness of a Patient-Centered, Nonphysician Led Self-Monitoring Blood Pressure Program in a Rural Federally Qualified Health Center.

Uncontrolled hypertension can lead to an increased risk of cardiovascular disease, myocardial infarction, stroke, or death. Self-monitoring blood pressure (SMBP) programs have been associated with blood pressure (BP) reduction, particularly among rural, minority, and low-income individuals. There is limited literature about nonphysician SMBP programs. To evaluate the effectiveness of an SMBP program designed to engage nonphysician team members in hypertension management within a federally qualified health center (FQHC). Self-monitoring blood pressure program activities were implemented using a Plan, Do, Study, Act model. The University of Washington Health Promotion Research Center evaluated processes and patient-level outcomes in a mixed-methods design. Quantitative analysis examined clinical outcomes related to hypertension, and qualitative analysis relied on interviews with clinical staff examining program implementation, adoption, and sustainability. Family Health Centers (FHCs), a FQHC located in rural Washington, serving medically underserved populations. Two hundred five active SMBP patients out of 2600 adult patients (over 18years old) who had a diagnosis of hypertension within the last 12months. Patients with uncontrolled hypertension were given a BP cuff to log their daily BP. Patients met with community health workers (CHWs) and medical staff to review logs and set self-management goals over 3 to 4months. Controlled BP measurements and factors to implementation and sustainment. Facilitators to implementation included expanded telehealth reimbursement during the COVID-19 pandemic, integration of CHWs, and linguistically adapted resources. Barriers included a lack of reimbursement for nonphysician time and BP monitors. Quantitative results demonstrated an effort to reach minoritized populations but did not show an improvement in BP outcomes. Family Health Center implemented an SMBP program adapted to meet the linguistic and social needs of their patients. The successful integration of CHWs and the need for reimbursement policies to support SMBP programs were key factors for implementation and sustainability.

Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients

BackgroundScreening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062).MethodsResearchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use.ResultsScreening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use.ConclusionsSelf-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.

130 Awareness and Implementation of Tobacco Control Practices in Rural Louisiana Federally Qualified Health Centers

OBJECTIVES/GOALS: Tobacco use remains a significant problem in rural America. Federally Qualified Health Centers (FQHCs) can help reduce the burden of tobacco use in rural areas. Still, we know little about center awareness and implementation of best practices for tobacco control. We assessed the knowledge and existence of tobacco control strategies in rural FQHCs. METHODS/STUDY POPULATION: We electronically surveyed health administrators and providers (n=33) in three rural Louisiana FQHCs between March and April 2021. The assessment measured awareness of the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use, center priority given to smoking cessation programming, the presence of best practices for tobacco control programming such as having a tobacco control champion and team, treatment and smoke-free campus policies, and referral to external cessation services. Descriptive statistics characterize survey respondents and responses. RESULTS/ANTICIPATED RESULTS: The majority of the respondents were female (88.5%), White (53.8%), between 35 and 54 years of age (69.2%), and non-smokers (65.4%). Among all respondents, 69.7% reported awareness of the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use. Less than half (48%) said their health center gave smoking cessation high priority relative to other health priorities. Only a third (36%) reported having a tobacco champion, and a quarter (25%) had a tobacco control team at their facility. Although all centers had a smoke-free campus policy, a quarter (27%) were unaware of the policy. Only a quarter (27%) reported having a written policy for smoking cessation treatment at their center, and a little more than half (56.7%) knew about cessation services to which they could refer tobacco users. DISCUSSION/SIGNIFICANCE: Centers had limited knowledge of the U.S. guideline for tobacco use treatment. Smoking cessation lacked priority, and tobacco control best practices implementation was low. FQHCs serving rural populations can implement guideline-recommend policies and clinical treatments, and future studies should test strategies to increase implementation.

Impact of Clinical Pharmacy Expansion within a Rural Federally Qualified Health Center through Implementation of Pharmacist-Led Medicare Annual Wellness Visits.

Medicare Annual Wellness Visits (AWVs) are annual appointments with the primary care team to prepare personalized prevention plans and focus on gaps in care. Although beneficial, AWVs are often difficult for providers to schedule and complete due to the increased time commitments compared to other visits. The purpose of this study was to assess the clinical, economic and patient-level value of newly implemented pharmacist-led AWVs within a rural Federally Qualified Health Center (FQHC). This retrospective, cohort study included patients who completed an AWV between 1 October 2021, and 14 February 2022. The primary objective was to compare the per clinician rate of completed AWVs between pharmacists and providers. The secondary objectives were to compare revenue generated, interventions made, and patient satisfaction between pharmacist- and provider-led AWVs. During the study period, nine providers completed 139 AWVs (15.4/provider) and two pharmacists completed 116 AWVs (58/pharmacist). Proportions of interventions ordered among those due in eligible patients were similar between pharmacists and providers (47.6% vs. 44.5%; p = 0.356). Patient satisfaction was overall positive with no difference between groups. Pharmacist-led AWVs increased completion of AWVs by 83% over a 20-week period, including significantly more initial, compared to subsequent, AWVs than providers. Sustainability of pharmacist-led AWVs at this FQHC is supported by study outcomes.

S253 Colorectal Cancer Screening Rates at Federally Qualified Health Centers in 2019 and 2020 Varied Based on Urban-Rural Status and Predominant Racial/Ethnic Group

Introduction: Over 30 million low-income and underinsured individuals in the U.S. receive primary care services, including colorectal cancer (CRC) screening, at Federally Qualified Health Centers (FQHCs). Given known differences in healthcare access in rural settings, we aimed to quantify CRC screening rates and factors associated with a decline in screening between 2019 and 2020 at FQHCs based on urban-rural status. Methods: We abstracted data from the Uniform Data System (UDS)—which compiles preventive health utilization data, including CRC screening rates among patients ages 50-74—for each FQHC. Our primary outcome was screening rate change (SRC), calculated as 2020 CRC screening rate minus 2019 CRC screening rate. We separated FQHCs based on urban-rural status and then created quartiles based on SRC. We used Wilcoxon Rank-Sum and x2 testing to compare rural and urban FQHCs and performed backward stepwise multivariable logistic regression to determine FQHC-level characteristics (2020 data) associated the largest decline in screening participation between 2019 and 2020 (SRC Q1 status). Results: In 2020, 734 urban and 527 rural FQHCs served 6,438,433 patients who were age-eligible for CRC screening. FQHC characteristics were significantly different between urban and rural FQHCs (Table). CRC screening rates were lower in rural FQHCs than urban FQHCs in 2019 (p=0.04) and 2020 (p< 0.0001), and SRC was lower in urban (-3.6%) than rural (-1.2%) FQHCs (p< 0.0001) (Table). Urban FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority non-Hispanic Black patients (aOR 2.05, 95%CI=1.19-3.52) or if they served a high proportion of uninsured patients (data not shown). Rural FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority Hispanic/Latinx patients (aOR 2.78, 95% CI=1.50-5.15) or if they were in a non-Medicaid expansion state (aOR 1.81, 95% CI 1.09-2.99) (data not shown). SRC was calculated by state for rural FQHCs and mapped in the Figure. Conclusion: Urban FQHCs had a greater decline in CRC screening rates from 2019 to 2020 than rural FQHCs and experienced larger declines if the patient population was predominantly Black or uninsured. Rural FQHCs saw a steep decline if they served a majority Hispanic/Latinx population or were in a non-Medicaid expansion state. These findings suggest that efforts to increase CRC screening at US FQHCs may need to be tailored to their location, demographics, and insurance and Medicaid eligibility status.Figure 1.: Map of screening rate change (2020 CRC screening rate – 2019 CRC screening rate) by state for rural FQHCs and indication of Medicaid expansion status as of 2020 Table 1. - FQHC characteristics (2020 data), colorectal cancer (CRC) screening rates (2019 and 2020), and screening rate changes (SRC) for urban and rural FQHCs in the US overall and by SRC comparison groups All FQHCs (n=1261) Urban FQHCs (n=734) Rural FQHCs (n=527) p-value* Frequency or percent SRC Q1 (n=218) SRC Q2+Q3+Q4 (n=516) Total (n=734) SRC Q1 (n=98) SRC Q2+Q3+Q4 (n=429) Total (n=527) Total patients eligible for CRC screening (age 50-74) 6,438,433 1,328,330 2,811,734 4,140,064 483,110 1,815,259 2,298,369 n/a CRC screening rate in 2019 (median %) 42.9 48.0 38.3 41.6 48.5 43.7 44.7 0.04 CRC screening rate in 2020 (median %) 38.8 32.4 38.8 36.9 32.7 43.9 42.4 < 0.0001 Median 2019-2020 SRC -2.7 -13.7 -1.2 -3.6 -12.6 0.1 -1.2 < 0.0001 Male patients (median %) 42.9 42.1 42.3 42.2 43.4 43.9 43.8 < 0.0001 Majority Race/Ethnicity served at FQHC (median %) Non-Hispanic White 36.4 16.0 25.2 21.7 66.9 70.4 70.1 < 0.0001 Non-Hispanic Black 8.2 12.7 19.1 17.3 2.6 1.6 1.6 < 0.0001 Hispanic/Latinx 15.8 33.4 24.7 26.8 7.7 5.5 6.1 < 0.0001 Other Non-Hispanic 4.6 5.2 5.9 5.7 2.5 3.4 3.3 < 0.0001 Patients with a preference for non-English Language (median %) 11.7 27.1 17.9 19.2 6.7 3.5 3.8 < 0.0001 Patients experiencing homelessness (median %) 1.8 3.2 2.6 2.7 1.1 1.0 1.0 < 0.0001 Patients with income Level >200% FPL (median %) 4.6 2.9 3.8 3.5 6.5 8.1 7.8 < 0.0001 Uninsured patients (median %) 19.6 23.9 21.5 22.3 19.7 16.2 16.7 < 0.0001 Medicaid Expansion (%) 71.6 76.6 73.6 74.5 59.2 69.5 67.6 0.007 *p-values represent Wilcoxon rank-sum or chisq tests comparing overall characteristics between urban and rural FQHCs.

The Role of a Federally Qualified Health Center in Identification and Management of an Occupational COVID-19 Outbreak: Lessons for Future Infection Surveillance and Response.

Federally Qualified Health Centers (FQHCs) have been essential in response to COVID-19 outbreaks among vulnerable populations. Our rural FQHC had a primary role in early detection of and response to a poultry plant-related outbreak at the outset of the pandemic that disproportionately and gravely affected the local Hispanic community. The health center activated a rapid local response that included the community's first mass testing event and first acute respiratory treatment clinic, both of which were central to abatement. Lessons learned from this experience provide important guidance for the potential role of FQHCs in infection outbreak preparedness in marginalized communities.

Implementing the 4Ms in a Rural Federally Qualified Health Center: Lessons Learned

The University of Louisville GWEP has partnered with Mountain Comprehensive Care, a FQHC with 9 practices in 5 rural counties in KY, to infuse the 4 M’s of age-friendly health care systems into their daily practices, namely what matters most, medication management, mentation and mobility. Many lessons were learned during this infusion period, specifically related to cultural and rural barriers that make some of these principles very difficult to implement. Specifically, what matters most to older adults in these very poor rural areas may not be the safest way to proceed; medication management may be difficult to do due to the extent of opioid addictions in these areas, mentation has many challenges related to isolation and lack of understanding of dementia and mobility issues are complicated due to the many home barriers to fall safety environments. These lessons will be discussed in this part of the symposium presentation.

Implementing a Substance Use Screening Protocol in Rural Federally Qualified Health Centers.

In 2018, nearly 20% of Americans aged 12 years and older reported using illicit substances, with higher rates in rural areas. Federally Qualified Health Centers (FQHCs) provide health care to one in five rural Americans. However, estimates suggest that only 13.6% of patients in rural FQHCs receive substance use (SU) screening compared with 42.6% of patients in urban FQHCs. This quality improvement (QI) project aimed to improve patient quality and safety and meet Health Resources and Services Administration reporting requirements. These aims were achieved through the design and implementation of a new SU screening protocol in four FQHCs in rural Indiana. Deming's plan-do-study-act model was used to implement QI interventions to increase SU screening rates. A new SU screening tool, the National Institute on Drug Abuse -Modified Alcohol, Smoking, and Substance Involvement Screening Testwas implemented, and staff were trained on its use. the screening, brief intervention, and referral to treatment model was used as a guiding framework. Outcome measures included a comparison of SU screening rates from the first quarter of 2019 to the first quarter of 2020, as well a pretest-posttest designed to measure staff knowledge and attitudes regarding SU. Baseline SU screening rate in 2019 was 0.87%. This increased to 24.8% by March 2020. Additionally, posttest results demonstrated improvement from staff on all indices, and an approval rating of 77% of the new SU screening practices. This project demonstrated that a low-cost QI intervention can increase SU screening rates in rural FQHCs, as well as improve staff knowledge and attitudes regarding SU.

Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia.

The purpose of this study is to evaluate the effectiveness of the West Virginia Program to Increase Colorectal Cancer Screening in implementing patient reminders to increase fecal immunochemical test (FIT) kit return rates in nine federally qualified health centers (FQHCs). Using process measures and cost data collected, the authors examined the differences in the intensity of the phone calls across FQHCs and compared them with the return rates achieved. They also reported the cost per kit successfully returned as a result of the intervention. Across all FQHCs, 5,041 FIT kits were ordered, and the initial return rate (without a reminder) was 41.1%. A total of 2,201 patients received reminder phone calls; on average, patients received 1.61 reminder calls each. The reminder interventions increased the average FIT kit return rate to 60.7%. The average total cost per FIT kit returned across all FQHCs was $60.18, and the average cost of only the reminders was $11.20 per FIT kit returned. FQHCs achieved an average increase of 19.6 percentage points in FIT kit return rates, and costs across clinics varied. Clinics with high-quality health information systems that enabled tracking of patients with minimal effort were able to implement lower cost reminder interventions.

Community Pharmacy Enhanced Dispensing Model to Improve Medication Access for Rural Patients Living with HIV

To demonstrate the utility of a community pharmacy-centric workflow for improving access to medications for high-risk, rural persons living with HIV (PLWH) in partnership with a Federally Qualified Health Center (FQHC). University-sponsored independent community pharmacy and rural FQHC providing care to PLWH. Patient-centered Pharmacy Program is a service designed to improve access to HIV medications for PLWH in rural Idaho. The service is delivered in partnership with a 340B-covered entity (FQHC). The workflow for the service in the community pharmacy is described in detail, including time assessments and descriptions of tools and forms developed for rollout. Quality improvement initiatives over three years are described. This service ensures medication access for rural PLWH and is sustainable for the community pharmacy. Expansion of services is feasible for the future. This partnership may be one that could be implemented at other rural, independent community pharmacies seeking to have outreach to rural patients with chronic medication needs.

Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients.

Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

THE CHALLENGES OF FACILITATING PRACTICE CHANGE INITIATIVES TO IMPROVE GERIATRIC CARE IN RURAL PRIMARY CARE

Background: The Carolina Geriatric Workforce Enhancement Program (CGWEP) integrated education and workflow modifications into four primary care practices in 2017 (Rural Federally Qualified Health Center, Family Medicine Clinics, and Internal Medicine Residency Program). Methods: The CGWEP partnered with practice support professionals in NC Area Health Education Centers (AHECs) to improve outcomes in falls, advanced care planning (ACP) and health literacy. Projects aligned with metrics included in the merit-based incentive payment systems and patient centered medical home criteria. Practices 1 and 2 focused on fall risk identification and reduction. Practice 1 emphasized clinic-wide education while Practice 2 reorganized workflows. Practice 3 chose to perform coaching of residents to facilitate ACP discussions. Practice 4 reorganized workflows and developed clinical competencies to improve efficiency. Results: Practices 1 and 2 - improvement in falls screening rates of 47% and 12% respectively. Intervention documentation improved by 93% and 17% respectively. Practice 3 - 3% improvement documentation of ACP education. Practice 4 -10% increase in practice productivity. Each practice experienced challenges with implementation of the PDSA plans. Through these projects the CGWEP team developed sixteen best practices to help address the challenges. Conclusions: Practice improvement resulted from innovative training of clinic staff, workflow redesign, and Plan, Do, Study, Act (PDSA) cycles. Enhancing geriatrics in primary care is most successful when projects are grounded in practice priorities aligned with existing quality metrics, provide whole team training, and develop efficiencies in practice workflow. PDSA evaluation cycles can identify new opportunities in workflow patterns and training.

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

BackgroundFederally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools.ExperienceThere was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH.RecommendationsWe make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs’ Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.

Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial.

(Reprinted with permission from American Journal of Psychiatry 2013; 170:414-425).

Improving Health Care for Spanish-Speaking Rural Dairy Farm Workers.

Dartmouth Geisel Migrant Health (DGMH) is a medical student group that provides on-site health services for Spanish-speaking dairy workers in rural Vermont and New Hampshire in conjunction with a federally qualified health center (FQHC). This project was undertaken to evaluate and improve the services provided by DGMH and the FQHC and to refine understanding of the target population. We surveyed 25 workers at 6 collaborating dairy farms to identify health priorities and concerns and perceived barriers and facilitators to health care for these workers. Surveys were administered over 2 weeks in July 2015. Interpreter-mediated appointment and sliding-fee-scale data from a period 7 months that spanned survey administration were also assessed. Diabetes and hypertension were the most common health concerns. Thirty-two percent of participants reported 10 or more days of depressed mood in the past month. Insurance and language were the most common barriers to health care and employers and on-site clinics were the most common facilitators. Appointments most often addressed women's health, gastrointestinal problems, health maintenance, diabetes, and back pain. Thirty FQHC sliding-fee-scale applications were completed by workers. These Spanish-speaking dairy-farm workers have many health concerns and perceive substantial barriers to health care. Collaboration between medical students, a rural FQHC, and farm employers provides important services that facilitate health care access among this population.

Connection between Depression and Inability to Fill Prescriptions in Rural FQHC Patients with Chronic Disease.

The purpose of this paper was to (1) examine the rates of elevated depression symptoms among a sample of rural Federally Qualified Health Center (FQHC) patients with chronic disease and (2) determine if an inability to afford general prescription medications within the past 12 months is a significant predictor of depression symptoms among these patients. These data came from Project EDUCATE, an ongoing five-year study designed to be a large-scale, multifocal examination of the needs and experiences of rural FQHC patients with hypertension and/or diabetes. A total of 497 rural FQHC patients completed surveys (including a series of psychosocial questions, the Multigroup Ethnic Identity Measure and the Center for Epidemiologic Studies Depression scale) as part of phase one of the project; 438 of these with complete data are included in the current analytic sample. Results revealed that 53.0% of the sample screened positive for depression, and over half of those who screened positive reported not being able to afford their prescription medications at least once within the past 12 months (51.3% vs. 26.3% non-depressed). Further, even after controlling for age, ethnic identity attachment, sex, education level, employment status, income, insurance status, recent inability to afford needed medical care, hypertensive status, mental health diagnosis, and family history of mental illness, patients who could not afford to fill their prescriptions in the past 12 months were 2.6 times as likely to screen positive for depression (ORADJ = 2.476, p = 0.002) as those who could afford their medications. Overall, results of this study suggest that, among rural patients diagnosed with chronic disease, depressive symptomatology may be alarmingly high and an inability to afford medications may be an important risk factor for depression symptoms. These results highlight the need for increased attention to prescription medication affordability among rural patients with chronic disease in order to reduce the risk of comorbid depression.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists.

Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care. To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists. During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications. Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications. A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients.

Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial

Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care. From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity. Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94-15.20) and remission (odds ratio=12.69, 95% CI=4.81-33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group. Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.

Sidebar: One Rural Federally Qualified Health Center’s Journey With North Carolina’s Improving Performance in Practice (IPIP) Program

Sidebar: One Rural Federally Qualified Health Center’s Journey With North Carolina’s Improving Performance in Practice (IPIP) Program