Rural Health
Research Gateway

John A. Gale, MS

Maine Rural Health Research Center

Phone: 207.228.8246
Fax: 207.228.8138
Email: john.gale@maine.edu

University of Southern Maine
PO Box 9300
34 Bedford Street
Portland, ME 04104-9300

Current Projects - (4)

  • Medical and Mental Health Service Provision Amongst Rural Health Clinics
    This study will provide a descriptive analysis of differences in Rural Health Clinic (RHC) type, clinic size, and geographic location of RHCs providing same day medical and mental health visits, compared to RHCs that are only providing one or the other type of visits on the same day.
    Research center: Maine Rural Health Research Center
    Topics: Health services, Mental and behavioral health, Rural Health Clinics (RHCs)
  • Psychiatric Bed Closures in Rural Hospitals: An Assessment of Trends, Impact, and Policy Strategies
    This study will examine trends in the closure of psychiatric beds by rural hospitals using the Substance Abuse and Mental Health Services Administration Treatment Services Locator; the American Hospital Association Annual Survey of Hospitals (2010-2017); and the Area Health Resources File.
    Research center: Maine Rural Health Research Center
    Topics: Healthcare access, Hospitals and clinics, Mental and behavioral health
  • Understanding Rural Health Clinic Services, Use, and Reimbursement
    This study describes the scope and intensity of services provided to Medicare beneficiaries by independent and provider-based Rural Health Clinics. It will also assess the adequacy of the Centers for Medicare & Medicaid Services' changes to the outpatient evaluation and management codes in 2021 compared to the 2021 per-visit reimbursement cap.
    Research center: Maine Rural Health Research Center
    Topics: Health services, Healthcare financing, Hospitals and clinics, Medicare, Rural Health Clinics (RHCs)
  • Use of Z Codes by Rural and Urban Providers to Capture Data on the Social Determinants of Health Impacting Medicare Beneficiaries
    Using a mixed methods approach, we will examine the use of Z codes by rural and urban providers to better capture information on the social determinants of health experienced by Medicare beneficiaries across the rural continuum.
    Research center: Maine Rural Health Research Center
    Topics: Health services, Medicare, Physicians, Social determinants of health

Completed Projects - (19)

  • Adolescent Alcohol Use in Rural Areas: What Are the Issues?
    This study will use the National Survey on Drug Use and Health (NSDUH) to examine the effect of developmental, individual, and environmental factors on adolescent alcohol use across the urban-rural continuum.
    Research center: Maine Rural Health Research Center
    Topic: Substance use and treatment
  • Analysis of 2004-2005 State Flex Grant Plans
    This project will analyze state Flex grant applications and related budget and work plan revisions focusing on state activities in the core Flex program areas of networks, quality improvement, and EMS.
    Research centers: Maine Rural Health Research Center, University of Minnesota Rural Health Research Center
    Topics: Emergency medical services (EMS) and trauma, Networking and collaboration, Quality, Rural Hospital Flexibility Program
  • Availability, Characteristics, and Role of Detoxification Services in Rural Areas
    This project will produce a comprehensive description of the distribution and characteristics of detoxification (detox) services across rural areas including a discussion of access issues, the role of detox services within local systems of care, barriers to the delivery of detox services by rural providers, and policy and regulatory incentives needed to encourage the development of rural detox services. Products will include a working paper and related journal articles addressing these topics.
    Research center: Maine Rural Health Research Center
    Topic: Substance use and treatment
  • Catastrophic Consequences: The Rise of Opioid Abuse in Rural Communities
    This project will analyze national data on the prevalence of opioids in rural and urban settings as well as describe state and local efforts to promote prevention and access to treatment.
    Research center: Maine Rural Health Research Center
    Topic: Substance use and treatment
  • Developing a Sentinel Cohort of Rural Health Clinics for Use in Developing Relevant Quality Measures and Monitoring Program Performance
    This two year project will assemble a cohort of Rural Health Clinics (RHCs) from ten to thirteen states to participate in a sentinel quality measurement process. During the first year of the project, the cohort of RHCs will participate in the identification, development, and refinement of a discrete set RHC quality measures in conjunction with the project team and an expert panel of RHC and quality measurement experts. During the second year, the cohort will be asked to implement, report, and evaluate the measures.
    Research center: Maine Rural Health Research Center
    Topics: Quality, Rural Health Clinics (RHCs)
  • Development of State Flex Program Logic Models and Related Toolkit
    Research center: Maine Rural Health Research Center
    Topic: Rural Hospital Flexibility Program
  • How are Rural Health Clinics Serving Pediatric and Obstetrical Medicaid Populations?
    This project examined the roles of independent and provider-based Rural Health Clinics in serving pediatric and obstetrical patients covered by state Medicaid programs.
    Research center: Maine Rural Health Research Center
    Topics: Children and adolescents, Health services, Healthcare financing, Maternal health, Medicaid and CHIP, Rural Health Clinics (RHCs), Women
  • Issues Related to Rural Health Clinic (RHC) Participation in CMS's Merit-Based Incentive Payment System (MIPS)
    This qualitative project focused on understanding the reporting requirements for Rural Health Clinics (RHCs) related to Centers for Medicare & Medicaid Services' (CMS) Merit-Based Incentive Payment System (MIPS) as well as the challenges in doing so and options to support RHC reporting.
    Research center: Maine Rural Health Research Center
    Topics: Quality, Rural Health Clinics (RHCs)
  • Measuring the Community Benefits and Impact of Critical Access Hospitals
    This project will develop, test, and implement a set of community benefits and impact indicators for Critical Access Hospitals (CAHs). These indicators will assist CAHs, policymakers, and rural stakeholders to understand the impact of CAHs on their communities and local health care delivery systems.
    Research center: Maine Rural Health Research Center
    Topic: Critical Access Hospitals (CAHs)
  • National Study of Rural Health Clinics
    Research center: Maine Rural Health Research Center
    Topics: Health services, Rural Health Clinics (RHCs)
  • National Study of Substance Abuse Prevalence and Treatment Services in Rural Areas
    This project will research the prevalence of the abuse of legal and illegal substances across rural populations and geographic areas, including the extent to which rural individuals are receiving treatment for their substance abuse and barriers to the receipt of treatment.
    Research center: Maine Rural Health Research Center
    Topics: Health disparities and health equity, Health services, Rural statistics and demographics, Substance use and treatment
  • Provision of Specialty Mental Health Services by Rural Health Clinics
    This project will document the extent to which Rural Health Clinics (RHCs) are employing mental health staff nationally, understand why more RHCs are not employing specialty mental health staff, and analyze the barriers to and opportunities for the delivery of mental health services by RHCs. The results will identify opportunities and interventions to encourage RHCs to offer this important service.
    Research center: Maine Rural Health Research Center
    Topics: Health services, Mental and behavioral health, Rural Health Clinics (RHCs), Substance use and treatment
  • Rural E-Mental Health: Models That Enhance Access, Service Delivery, and Integration of Care
    E-mental health programs have been developed in rural areas as a promising approach to address the chronic challenges of low availability of mental health clinicians, long travel distances, and stigma surrounding mental health care. The literature has established the technical feasibility of these programs and interest remains strong in developing and implementing them more broadly. However, we lack a clear understanding of the viability of current rural e-mental health programs - both the business case for starting and sustaining them and the clinical case for what services and functions may be provided _ and what impact they have had. The current rural health environment is changing significantly and it is important to understand where and how e-mental health programs have been established and sustained, what impact they have had, and what value they may add to other initiatives. To address this gap we will conduct interviews with between 24-30 current rural e-mental health programs.
    Research center: Maine Rural Health Research Center
    Topics: Mental and behavioral health, Telehealth
  • Rural Health Clinic Financial Performance and Productivity
    This study used Medicare cost reports for independent and provider-based clinics to provide a detailed national picture of the financial and operational performance of RHCs and describe variations in performance related to revenue, costs, staffing, payer mix, productivity levels, and hours of operation across independent and provider-based clinics. The project also developed measures that can be used to benchmark RHC performance over time.
    Research center: Maine Rural Health Research Center
    Topics: Medicare, Rural Health Clinics (RHCs)
  • Rural Health Clinics Chartbook
    This project produced a comprehensive, descriptive chartbook detailing the characteristics and status of rural health clinics (RHCs) nationally. It also assessed the use of secondary data to construct a national set of indicators for RHCs and identify gaps in our knowledge that cannot be addressed using secondary data.
    Research center: Maine Rural Health Research Center
    Topic: Rural Health Clinics (RHCs)
  • Safety Net Activities of Independent Rural Health Clinics
    This national study will investigate and describe the safety net role of independent Rural Health Clinics (RHC). It will further examine the market effect of Federally Qualified Health Centers (FQHC) on the safety net role of independent RHCs at the county level.
    Research center: Maine Rural Health Research Center
    Topics: Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs)
  • Special Study of EMS Issues
    This study will focus on state, community, and hospital level initiatives designed to build the infrastructure to support EMS service capacity and encourage the integration of these services into the rural healthcare infrastructure in the areas of quality improvement, financing, staffing, medical control, and networking and integration.
    Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Emergency medical services (EMS) and trauma, Networking and collaboration
  • Transformation of Rural Health Clinics: Are They Ready to Serve as Patient-Centered Medical Homes?
    Rural Health Clinics (RHCs) face pressure to transform their practices by becoming patient-centered medical homes (PCMHs). This study will document the readiness of RHCs to serve as PCMHs and provide information to assist policymakers in developing technical assistance and other policy resources to support RHCs in doing so.
    Research center: Maine Rural Health Research Center
    Topics: Care management, Rural Health Clinics (RHCs)
  • Using Program Logic Models to Monitor the Performance of State Flex Programs
    This project will use a program logic model approach to track state program activities and develop tools that allow states to systematically monitor and manage their accomplishments in the context of Flex Program goals.
    Research center: Maine Rural Health Research Center
    Topic: Rural Hospital Flexibility Program

Publications - (43)

2024

2022

2019

  • Rural Health Clinic Costs and Medicare Reimbursement
    Policy Brief
    Maine Rural Health Research Center
    Date: 11/2019
    We used cost report data to examine Rural Health Clinic (RHC) services costs. The findings support the National Advisory Committee on Rural Health & Human Service's conclusion that the cost-based methodology used to determine Medicare reimbursement for RHCs is outdated and RHCs subject to the reimbursement cap are paid less than their costs.

2018

2017

  • Rural Opioid Prevention and Treatment Strategies: The Experience in Four States
    Policy Brief
    Maine Rural Health Research Center
    Date: 04/2017
    Little is known about what states with large rural populations are doing to combat opioid use disorders (OUD) in rural communities. This qualitative study identified rural challenges to the provision of OUD prevention, treatment, and recovery services and explored promising strategies to tackle the opioid crisis in rural communities.

2016

  • Understanding the Business Case for Telemental Health in Rural Communities
    Journal Article
    Maine Rural Health Research Center
    Date: 07/2016
    This article describes the current landscape and characteristics of rural telemental health programs and then examines their business case.
  • Health Information Exchange: A Strategy for Improving Access for Rural Veterans in the Maine Flex Rural Veterans Health Access Program
    Maine Rural Health Research Center
    Date: 05/2016
    This paper reports on the design and implementation of a first-in-the-nation project to expand rural veterans' access to healthcare by establishing a bi-directional connection between Maine's statewide health information exchange (HIE) and Veterans Administration facilities and centers.
  • Pilot Testing a Rural Health Clinic Quality Measurement Reporting System
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2016
    More than 4,000 Rural Health Clinics (RHCs) serve the primary care needs of rural communities. Unfortunately, the Rural Health Clinic Program is plagued by a lack of data participating clinics. This reports on the results with a focus on assessing the feasibility and utility of the reporting system and quality measures for the participating RHCs.
  • Rural Opioid Abuse: Prevalence and User Characteristics
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2016
    Opioid abuse is the fastest growing substance abuse problem in the nation and the primary cause of unintentional drug overdose deaths. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socioeconomic characteristics associated with their use and other risky behavior.

2015

2014

2013

  • Telemental Health in Today's Rural Health System
    Maine Rural Health Research Center
    Date: 12/2013
    This policy brief describes the organizational setting, services provided, and staff used in 53 telemental rural health programs. It also outlines the opportunities and challenges for telemental health in the rural health system.
  • Rural Vets: Their Barriers, Problems, Needs
    Journal Article
    Maine Rural Health Research Center
    Date: 05/2013
    Evolving population trends--the aging of rural veterans, the growing number of female veterans and rates of homelessness among veterans--place significant demands on VA and rural delivery systems. Coordination among healthcare providers is essential to increasing the availability of services and expanding veteran outreach programs.

2012

2010

  • Are Rural Health Clinics Part of the Rural Safety Net?
    Policy Brief
    Maine Rural Health Research Center
    Date: 09/2010
    This policy brief examines whether rural health clinics are part of the rural safety net.
  • Safety Net Activities of Independent Rural Health Clinics
    Maine Rural Health Research Center
    Date: 09/2010
    Rural Health Clinics (RHCs) provide primary care services to rural residents of 45 states. Since RHCs are in underserved rural areas and serve vulnerable populations, many consider them safety net providers. In this paper, we explore whether, and to what extent, independent RHCs are serving a safety net role or have the capacity to do so.
  • Encouraging Rural Health Clinics to Provide Mental Health Services: What Are the Options?
    Maine Rural Health Research Center
    Date: 05/2010
    This study examined changes in the delivery of mental health services by rural health clinics (RHCs), their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services.
  • The Provision of Mental Health Services by Rural Health Clinics
    Maine Rural Health Research Center
    Date: 05/2010
    This study examined changes in the delivery of mental health services by rural health clinics (RHCs), their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services.
  • Monitoring the Community Benefits of CAHs: A Review of the Data (Briefing Paper)
    Maine Rural Health Research Center
    Date: 03/2010
    There is a growing national interest in the benefits provided by nonprofit and public hospitals to their communities in exchange for the tax benefits or public funding that they receive.
  • Monitoring the Community Benefits of Critical Access Hospitals: A Review of the Data
    Policy Brief
    Maine Rural Health Research Center
    Date: 03/2010
    This brief examines the community benefit activities of critical access hospitals (CAHs) using data from the Flex Monitoring Team's (FMT) pilot test of a set of community benefit data collection tools and performance indicators, the Internal Review Service's (IRS) 2006 Hospital Compliance Study, and the 2007 FMT CAH survey.

2009

  • Availability, Characteristics, and Role of Detoxification Services in Rural Areas
    Maine Rural Health Research Center
    Date: 12/2009
    Few detox providers (n=235) serve rural America; 82% of rural residents live in a county without a detox provider. More than half of all rural detox providers serve patients across a 100-mile radius, making travel distances a barrier to outpatient care. Referral options to substance abuse treatment are limited, especially in isolated rural areas.
  • Few and Far Away: Detoxification Services in Rural Areas (Research & Policy Brief)
    Maine Rural Health Research Center
    Date: 12/2009
    This policy brief finds that few rural detox providers exist; 82% of rural residents live in a county without a detox provider. More than half of all rural detox providers serve a 100-mile radius. Travel distances are a barrier to outpatient detox models. Referral options to substance abuse treatment are limited, especially in isolated rural areas.

2008

2007

  • Distribution of Substance Abuse Treatment Facilities Across the Rural - Urban Continuum
    Maine Rural Health Research Center
    Date: 10/2007
    This study examines the distribution of substance abuse treatment services across the continuum of rural and urban counties, identifying the type and intensity of services provided.
  • State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 10/2007
    This report explores activities funded by the Medicare Rural Hospital Flexibility Program (Flex Program) to strengthen the rural healthcare infrastructure and discusses which activities were considered most successful by state Flex coordinators.
  • State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program (Policy Brief)
    Policy Brief
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 04/2007
    To understand the priorities/accomplishments of state Flex Grant Programs, the Flex Monitoring Team asked Flex coordinators to identify and discuss their states' three most successful initiatives in the last two years. Interviews were conducted with Flex coordinators and State Office of Rural Health staff in 45 states.
  • The Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 02/2007
    This policy brief discusses the findings of a project to understand the community involvement and impact of critical access hospitals and the Medicare Rural Hospital Flexibility Program (Flex Program).
  • Exploring the Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 01/2007
    This paper reports on a series of site visits to six diverse rural communities and critical access hospitals to assess the experiences and impact of these hospitals in responding to their community's health infrastructure needs.
  • Use of Critical Access Hospital Emergency Rooms by Patients With Mental Health Symptoms
    Journal Article
    Maine Rural Health Research Center
    Date: 2007
    Describes the results of a study investigating the use of critical access hospital (CAH) emergency rooms by patients with mental health problems to understand the role these facilities play in rural mental health needs and the challenges they face.

2006

  • Quality and Performance Improvement Grant Activities Under the Flex Program
    Maine Rural Health Research Center
    Date: 08/2006
    This paper describes quality and performance improvement activities proposed by states during the 2005 grant year under the Medicare Rural Health Flexibility Program.
  • Creating Program Logic Models: A Toolkit for State Flex Programs
    Maine Rural Health Research Center
    Date: 04/2006
    This is a tool for planning, managing, reporting on, and assessing Flex Program goals, activities, and accomplishments; assistance in identifying/defining measurable outcomes; information linking state-level Flex Program strategies to measurable outcomes; and a consistent program-reporting framework to share results internally and externally.
  • A Review of State Flex Program Plans, 2004-2005
    Maine Rural Health Research Center, University of Minnesota Rural Health Research Center
    Date: 03/2006
    This paper examines the objectives and project activities proposed by states in their Medicare Rural Hospital Flexibility Program (Flex Program) grant applications for Fiscal Year 2004 to strengthen the rural healthcare infrastructure in their states. It highlights recent trends in state Flex Program planning, development, and implementation.
  • Emergency Medical Services (EMS) Activities Funded by the Medicare Rural Hospital Flexibility Program
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2006
    This paper describes the emergency medical services-related activities that the 45 states receiving funding from the Medicare Rural Hospital Flexibility (Flex) Program proposed to conduct in fiscal year 2004-05.
  • Mental Healthcare in Rural Communities: The Once and Future Role of Primary Care
    Journal Article
    Maine Rural Health Research Center
    Date: 2006
    Discusses issues related to the delivery of mental health services in the United States. Addresses how these issues complicate the delivery of services in rural areas. Offers an argument for integrating primary care and mental health in rural areas.
  • Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices
    Maine Rural Health Research Center
    Date: 2006
    This report discusses barriers to mental and behavioral health service delivery in rural America. It includes model programs and model policy strategies for rural mental and behavioral healthcare delivery and discusses the roles that telehealth and that the State Offices of Rural Health should play in service delivery.

2005

2004

  • Comparative Performance Data for Critical Access Hospitals
    Journal Article
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
    Date: 2004
    Discusses the potential use of comparative performance data for critical access hospitals (CPD-CAH) to facilitate performance and quality improvement. Covers potential benefits and drawbacks of CPD-CH and identifies issues in the development and implementation of CPD-CAH.

2003

  • The Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook
    Chartbook
    Maine Rural Health Research Center
    Date: 01/2003
    This chartbook reports on a rural health clinics (RHCs) survey. Information was collected on many topics, including their characteristics/operations; their location relative to the underservice problems/rural access needs; their safety net functions; staffing, recruitment, and financial issues; and involvement in training healthcare professionals.

2001

  • Medicaid Managed Behavioral Health Programs in Rural Areas
    Policy Brief
    Maine Rural Health Research Center
    Date: 08/2001
    This research and policy brief studies which states have implemented Medicaid-managed behavioral health programs in rural areas. It describes the programs in terms of Medicaid populations served, program design, and implementation model and the experience of programs regarding access to/coordination of services.
  • Medicaid Managed Behavioral Health in Rural Areas
    Maine Rural Health Research Center
    Date: 01/2001
    This study of which states have implemented Medicaid managed behavioral health (MMBH) programs in rural areas describes these programs in terms of Medicaid populations served, program design, and implementation model. It also describes the experience of programs regarding access to and coordination of services.