Health Care Accessibility for Chronic Illness Management and End-of-Life Care: A View from Rural America

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See Parekh Barton , supra note 5.

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Census Bureau definitions are complex. HHS takes CB geographic classifications and simplifies that terminology to fit their concerns (as does HUD for housing, etc). Rural versus frontier is a good example. These designations are based on populating density and regional service capacity for services such as health care; there is correlation between “frontier” and “underserved” (i.e., HUD does not use “frontier”). Many terms are used to refer to the continuum of geographic areas. For the 2000 census, the U.S. Census Bureau's classification of “rural” consists of all territory, population, and housing units located outside urban areas and urban clusters. The Census Bureau classified as “urban” all territory, population, and housing units located within (1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and (2) surrounding census blocks that have an overall density of at least 500 people per square mile. “Frontier counties” have a population density of less than 7 people per square mile; thus, residents may have to travel long distances for care, see U.S. Census Bureau, available at <http://www.census.gov/geo/www/ua/ua_2k.html> (last visited March 3, 2011).

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See Zigmond , supra note 47; see also the Henry J. Kaiser Family Foundation, “To Hospitalize or Not to Hospitalize” Medical Care for Long-Term Care Facility Residents,” available at <www.kff.org/medicare/8110.cfm> (last visited October 16, 2010).

See Jacobsen , supra note 48.

See Bodenheimer , supra note 12.

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See Niemira Townsend , supra note 44.

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See Campbell , supra note 41.

Despite this modification for nurse practitioners at the federal level, some states have regulatory policies that make this difficult to implement, so the potential to increase and monitor hospice patients is really a state by state problem, not a federal one. Personal communication from Ronald Crossno to author [KEA] (October 31, 2010).

Virnig B. A. Moscovice I. Durham S. Casey M. , “Do Rural Elders Have Limited Access to Medicare Hospice Services?” Journal of the American Geriatrics Society 52, no. 5 (2004): 731–735; see also Brems C. Johnson M. E. Warner T. D. Roberts L. W. , “Barriers to Healthcare as Reported by Rural and Urban Interprofessional Providers,” Journal of Interprofessional Care 20, no. 2 (2006): 105 118.

See Glover , supra note 42; see also Niemira Townsend , supra note 44.

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See Wennberg , supra note 24; see also Beasley (id.)

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A Critical Access Hospital (CAH) is a hospital that is certified to receive cost-based reimbursement from Medicare. The reimbursement that CAH's receive is intended to improve their financial performance and thereby reduce hospital closures. Each hospital must review its own situation to determine if CAH status would be advantageous. CAH's are certified under a different set of Medicare conditions of participation (CoP) that are more flexible that an acute care hospitals CoP. A map marking the location of CAH's can be accessed at <http://www.flexmonitoring.org/documents/CAH_09_30_10.pdf> (last visited March 3, 2011). As of September, 2010, there were 1, 320 certified Critical Access Hospitals located throughout the U.S. CAH's must be located in a rural area and meet one of the following criteria: (1) located 35 miles or more from another hospital or 15 miles from another hospital in mountainous terrain or areas with only secondary roads. More detailed information can be accessed in a letter sent from CMS to State Survey Agency Directors September 7, 2007, available at <http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter07–35.pdf> (last visited March 3, 2011).

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See Beasley , supra note 72.

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See Wennberg , supra note 24.

See Wennberg , supra note 7.

See Fisher , supra note 19; see also Wennberg , supra note 24. According to the Dartmouth Institute for Health Policy and Clinical Practice (TDI), cost needs to be taken into account when expanding capacity as well as care management models outside of the acute care setting. Successful models of quality such as the Mayo Clinic deliver higher quality of care at a lower cost with good outcomes. However, these highly organized systems of care cannot be expected to grow without appropriate incentives.

See Fisher , supra note 19.

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See Coburn , supra note 74; see also Fisher , supra note 19.

See Beasley , supra note 72.

See Campbell , supra note 41; and personal communication from Michael Knower to author (KEA) (October 19, 2010).

See Wennberg , supra note 11, at 46.

See Dartmouth Institute for Health Policy and Clinical Practice, supra note 24; see also Fisher E. S. Wennberg D. E. Stukel T. A. Gottlieb D. J. Lucas F. L. Pinder E. L. , “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 138, no. 4 (2003): 288–298; Blendo R. J. Benson J. M. , “Understanding How Americans View Healthcare Reform,” New England Journal of Medicine 361, no. 9 (2009): E13.