文章基本信息

标题：Care in the Country: A Historical Case Study of Long-Term Sustainability in 4 Rural Health Centers
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作者：D. Brad Wright
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：99
期号：9
页码：1612-1618
DOI：10.2105/AJPH.2008.146050
语种：English
出版社：American Public Health Association
摘要：From 1978 to 1983, researchers at the University of North Carolina conducted a National Evaluation of Rural Primary Care Programs. Thirty years later, many of the programs they studied have closed, but the challenges of providing rural health care have persisted. I explored the histories of 4 surviving rural primary care programs and identified factors that contributed to their sustainability. These included physician advocates, innovative practices, organizational flexibility, and community integration. As rural health programs look ahead, identifying future generations of physician advocates is a crucial next step in developing the rural primary care workforce. It is also important for these programs to find ways to cope with high rates of staff turnover. The health care system in the rural United States faces many challenges. Compared with urban populations, rural residents are more likely to be low income, uninsured, and in poor health.¹ Per capita federal spending on rural health, despite an arguably greater need for services, is not quite half that for health care nationally.² Limited resources impose financial constraints on rural primary care programs that provide a large amount of uncompensated care, which in turn threatens organizational sustainability. Rural primary care programs are the sole source of health care in many communities; thus their survival is vitally important. From 1978 to 1983, researchers at the Health Services Research Center (now the Cecil G. Sheps Center for Health Services Research) at the University of North Carolina at Chapel Hill undertook a comprehensive study of rural primary care programs. At the time, there was a major push by government, advocates, and health services researchers to expand primary care programs in rural areas but uncertainty about the best way to do so. The National Evaluation of Rural Primary Care Programs (hereafter, National Evaluation) sought to categorize rural primary care programs and assess their relative effectiveness. The National Evaluation identified and contacted 998 organizations—all externally supported rural primary care programs existing in the United States as of 1979. Of those, 640 responded and met inclusion criteria, and 467 programs in operation for more than a year were selected for further study. Five types of organization were identified: comprehensive health centers, group practices, institutional extension practices, free-standing primary care centers, and solo physician practices. Stratified random samples were drawn to ensure representation of each program type in subsequent parts of the National Evaluation. The researchers conducted site visits for 40 programs. Their methods are discussed more fully elsewhere.^{3 – 6} The National Evaluation found that the majority of programs had difficulty covering their expenses. Financial instability threatened the long-term sustainability of many programs, and roughly 1 in 4 programs reported difficulty recruiting and retaining clinical staff.³ In the 25 years since the original evaluation, 10 of the 40 programs have ceased to operate. A sizable literature, including an entire issue of Health Services Research , has reported on factors leading to such facility and program closures.^{7 – 11} Shi et al. followed up the original study with a quantitative examination of rural primary care program survival in 1978 to 1987.¹² I documented the history of 4 of the 30 programs that participated in the original evaluation and are still in operation and explored the factors that allowed these programs to continue operating in the face of financial and other barriers that threatened their long-term sustainability. I employed qualitative methods and recent data to better understand the phenomenon of sustainability.