The Journal Of Rural Health[JOURNAL]
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200 papers
Early Evidence of Geographic Variation in Medicare Participation Among Newly Eligible Mental Health Providers Following the 2024 Coverage Expansion.
Graves JM, Oster NV, Garberson LA … +2 more , Patterson DG, Andrilla CHA
J Rural Health · 2026 Jun · PMID 42394621 · Full text
PURPOSE: To assess changes in marriage and family therapist (MFT) and mental health counselor (MHC) workforce distribution from April 2022 to October 2024, evaluating early impacts of Medicare's coverage expansion on pro...
PURPOSE: To assess changes in marriage and family therapist (MFT) and mental health counselor (MHC) workforce distribution from April 2022 to October 2024, evaluating early impacts of Medicare's coverage expansion on provider participation in underserved rural communities. METHODS: This repeat cross-sectional study used Medicare Fee-for-Service Public Provider Enrollment Files and National Provider Identifier Registry data. Counties were categorized as metropolitan and rural (micropolitan or noncore) using Urban Influence Codes. We analyzed quarterly changes in Medicare participation and the proportion of counties with at least one participating provider across geographic categories. RESULTS: From April 2022 to October 2024, MFTs participating in Medicare increased from 111 to 9394, and MHCs increased from 4013 to 24013. Initially, participation rates were low and did not differ significantly by rurality. By October 2024, participation rates were higher in rural versus metropolitan counties for both provider types (MFTs: 16.4% rural vs. 11.0% metropolitan; MHCs: 12.1% vs. 9.2%; both p < 0.001). The percentage of counties with at least one Medicare-participating MFT increased from 2.5% to 26.5%, and from 27.2% to 55.8% for MHCs. However, only 7.4% of noncore counties had at least one Medicare-participating MFT in October 2024, and 32.2% had at least one MHC. CONCLUSIONS: Medicare participation among MFTs and MHCs increased dramatically following the 2024 coverage expansion, especially among rural providers. However, absolute provider availability in rural counties remains low, underscoring the need for additional strategies to translate participation gains into meaningful improvements in rural mental health access.
The Effect of Rural Versus Urban Residence on Risk of Unplanned Readmission and Death in Older Veterans Discharged From VA Hospitals.
Daggy JK, Perkins AJ, Ross-Driscoll K … +8 more , Myers LJ, Taylor SE, Reeves MJ, Arling G, Roy I, Hartronft SR, Schubert CC, Bravata DM
J Rural Health · 2026 Jun · PMID 42394595 · Full text
PURPOSE: Evidence suggests that rural-residing adults-compared with urban-may be at greater risk of readmission and mortality. Operational leaders within the Department of Veterans Affairs (VA) Geriatric Learning Health...
PURPOSE: Evidence suggests that rural-residing adults-compared with urban-may be at greater risk of readmission and mortality. Operational leaders within the Department of Veterans Affairs (VA) Geriatric Learning Health System (GLHS) sought to understand the effects of rural residence on readmission and mortality risk for older Veterans discharged from hospital to home. METHODS: This observational cohort study included Veterans aged ≥ 65 years discharged from VA hospitals (fiscal year 2023) to home. A semi-competing risk model was fit to jointly model unplanned readmission, mortality, and mortality after readmission, with rural residence as the exposure of interest. Data were censored at 30-days, 90-days, or 1-year post discharge to examine short- and longer-term effects. Additional variables considered for the model were identified through prior literature, clinical significance and those selected by the Centers for Medicare & Medicaid Services for unplanned readmission. FINDINGS: Among 99,557 patients (120 hospitals), 28.4% were rural residents. Only 18% of rural residents lived within 30 min of a VA facility versus 80.3% of urban residents. At 30 days, compared to urban, rural-residing patients had a 5% lower risk of readmission (hazard ratio [HR] = 0.95, 95% confidence interval [CI] = [0.91-1.00]), 20% higher risk of mortality (HR = 1.20, 95% CI = [1.03-1.40]), and a similarly higher risk of mortality after readmission (HR = 1.19, 95% CI = [1.03-1.39]). CONCLUSION: Rural-residing older Veterans had lower risk of readmission but higher risk of mortality. These findings will guide future VA GLHSs: seeking modifiable factors (e.g., social drivers of health, timely services) associated with mortality risk among rural Veterans that can inform practice, policy, and quality improvement, thereby reducing disparities in outcomes.
Bridging the Rural Mental Health Gap: Telehealth Delivery of Specialized CBT and MBCT for Veterans With Parkinson's Disease.
Purcell JR, Perskaudas R, Miller RB … +22 more , Hill LS, King A, Reddy V, Gilleran K, Marsh L, Sarwar A, Mack J, Duda JE, Lehosit J, Tineo P, Hinojosa-Lindsey M, Ketchum K, Kalkstein S, Shouse M, Maloney K, Liong C, Makin A, Glenn G, McHale D, O'Connor S, Interian A, Dobkin RD
J Rural Health · 2026 Mar · PMID 42310995 · Full text
PURPOSE: The Veteran Affairs (VA) New Jersey Parkinson's Disease (PD) Telepsychotherapy Hub (PD Telepsych Hub) delivers virtual mental health treatments to underserved rural Veterans in partnership with VA Parkinson's Di...
PURPOSE: The Veteran Affairs (VA) New Jersey Parkinson's Disease (PD) Telepsychotherapy Hub (PD Telepsych Hub) delivers virtual mental health treatments to underserved rural Veterans in partnership with VA Parkinson's Disease Research, Education, and Clinical Centers (PADRECCs). This manuscript outlines the PD Telepsych Hub's hybrid type 2 implementation-effectiveness framework then presents the clinical and demographic characteristics of Enrolled Veterans along with mental health outcomes for Treatment Engagers receiving individual Cognitive Behavioral Therapy (CBT-PD) or group Mindfulness-Based Cognitive Therapy (MBCT-PD) over the first 5 years of operation (10/2020 to 09/2025). METHODS: Underserved rural Veterans with PD were primarily directly outreached by the PD Telepsych Hub (64%) or referred by VA clinicians. Veterans who met screening criteria and completed a psychiatric consult were enrolled and offered CBT-PD or MBCT-PD via telehealth according to preferences and needs. Enrolled Veterans completed baseline questionnaires assessing demographics and health characteristics. Treatment Engagers completed pre-and-post measures of mood, anxiety, loneliness, functional change, and treatment satisfaction. RESULTS: Enrolled Veterans (N = 522 across 31 states) were rural (72%), 6% Hispanic, 8% people of color, and on average 71-years-old. They reported an average of 7 years since PD diagnosis. Although most met criteria for a mood disorder (86%) and 43% had psychiatric comorbidities, only 9% were receiving psychotherapy at time of program enrollment. CBT-PD (n = 202) significantly reduced depression and anxiety, while MCBT-PD (n = 38) reduced depression. Treatment Engagers (n = 240) overall reported high treatment satisfaction (94%). CONCLUSION: At baseline, the mismatch between care access and clinical need was striking. Results highlight a growing foundation for real-world effectiveness in delivering empirically supported, PD-adapted interventions via telehealth to the highest-need, lowest-access populations.
Relationship Between Food Security and Walking for Transportation: Findings by Region and Rurality.
Stroope J, Wende ME, Anderson RE … +4 more , Balis LE, Valentine Goins K, Bridges Hamilton CN, Umstattd Meyer MR
J Rural Health · 2026 Mar · PMID 42304978 · Full text
PURPOSE: Lack of transportation increases the risk of food insecurity. However, little is known about how food security relates to active transportation when considering rurality and the US region of the country. A bette...
PURPOSE: Lack of transportation increases the risk of food insecurity. However, little is known about how food security relates to active transportation when considering rurality and the US region of the country. A better understanding could lead to active transportation interventions that connect individuals with low food security to high-quality food access points. METHODS: To examine the relationship between food security and days per week of transport walking, we employed a negative binomial regression analysis with survey weights using data from the 2022 National Health Interview Survey (N = 27,651). To test whether region or rural-urban status modifies relationships, we included interaction terms in the model. Covariates include age, sex, education, race/ethnicity, self-rated health, urban-rural status, and US region. FINDINGS: Food security has a significant relationship with transport walking in rural and urban communities. This association did not significantly differ between rural and urban communities (second difference = 0.084; p > 0.369). Food security was significantly associated with transport walking across all regions, and the relationship strength did not significantly differ by region (all second differences p > 0.25). In the fully adjusted model, food insecurity was significantly associated with greater transport walking (b = 0.37, 95% CI: 0.24, 0.49, p < 0.001). CONCLUSIONS: Regardless of rural-urban status or region of US residency, individuals experiencing food insecurity walk for transportation more than persons with food security. Special consideration needs to be given to transport walking infrastructure that facilitates access to food across the United States, including rural communities.
Rural-Urban Differences in Use of Mental Health Care for Serious Mental Illness at the Veterans Health Administration: A Retrospective Cohort Analysis.
Caloudas AB, Amspoker AB, Smith A … +6 more , Chen L, Cuellar AK, Day G, Zingg A, Hogan J, Lindsay JA
J Rural Health · 2026 Mar · PMID 42304940 · Full text
PURPOSE: Rural Veterans with serious mental illness (SMI) encounter significant barriers to accessing mental health care, related to SMI symptoms and rurality. A 2023 Government Accountability Office report found that ru...
PURPOSE: Rural Veterans with serious mental illness (SMI) encounter significant barriers to accessing mental health care, related to SMI symptoms and rurality. A 2023 Government Accountability Office report found that rural Veterans used Veterans Health Administration (VHA) intensive mental health care for SMI less than urban Veterans relative to their population distributions. Our purpose was to deepen understanding of rural-urban differences in use of VHA mental health care among Veterans with SMI. METHODS: Using VHA databases, we conducted a retrospective cohort analysis of 387,477 Veterans diagnosed with SMI, examining rurality as a predictor of intensive care for SMI and other outpatient mental health services. FINDINGS: Of 387,477 Veterans with SMI in VHA care in FY18-FY22, 28% were rural. Compared to urban Veterans, a greater frequency of rural Veterans had mental health comorbidities including anxiety and posttraumatic stress disorder. Despite a higher burden of mental health conditions, rural Veterans with SMI had lower odds of receiving SMI care (38%), a video-to-home telehealth mental health encounter (15%), an outpatient mental health encounter (13%), and multidisciplinary care (10%). These findings remained after accounting for key potential exploratory factors. Older age, White race, non-Hispanic/Latino ethnicity, being male, being widowed, and not having service connection were linked to lower odds of receiving later mental health care in unadjusted models. CONCLUSIONS: Rural Veterans with SMI use VHA mental health care less than their urban counterparts. Given that VHA offers Veterans robust, specialized mental health services for SMI, research urgently needs to identify effective strategies for addressing barriers rural Veterans with SMI might face in using VHA-delivered mental health care.
Tailoring the Relational Playbook for Cardiology Teams to the Rural Hospital Medicine Setting: A Multi-Method Pre-Implementation Evaluation.
Gilmartin HM, Perry P, Connelly B … +9 more , Daus M, Ladebue A, Hess E, Morgan B, Nolan JP, Sjoberg H, Subramaniam S, Anderson ML, Leonard C
J Rural Health · 2026 Mar · PMID 42298752 · Full text
PURPOSE: The Relational Playbook for Cardiology Teams is a 6-month, evidence-based leadership development program designed to foster supportive learning environments within the Veterans Health Administration (VA). The Pl...
PURPOSE: The Relational Playbook for Cardiology Teams is a 6-month, evidence-based leadership development program designed to foster supportive learning environments within the Veterans Health Administration (VA). The Playbook features 50 leadership practices and resources, including readings, clinical examples, videos, and podcasts for flexible, asynchronous learning. Participants complete monthly independent study and implement 11 interventions during team meetings or one-on-one interactions. While rural healthcare settings may benefit from the Playbook, adaptations are needed to ensure acceptability, appropriateness, and feasibility. This study aimed to tailor the Playbook for rural hospital medicine using a theory-informed multi-method pre-implementation approach. METHODS: Clinical leaders in medicine, nursing, social work, and pharmacy were recruited from three rural VA hospitals. Facility-level data were drawn from the 2023 VA Support Service Center Capital Assets database and the VA Hospital Medicine Survey. Observational data from site visits were collected using a structured template and analyzed through team-based rapid qualitative content analysis. FINDINGS: In 2024, we conducted three site visits at intermediate-complexity VA hospitals serving rural Veterans. Clinical leaders at each site reported potential barriers to engagement, including leadership instability, physician burnout, and limited time for professional development. Tailoring strategies were recommended, including expanding recruitment to all clinical leaders, streamlining site visits, and using publicly available data to contextualize site-specific challenges. CONCLUSION: A multi-method pre-implementation approach enabled effective adaptation of the Playbook, improving its relevance for rural settings. Early engagement and flexible implementation are key to successful adaptation. Future evaluation will assess impact on team dynamics and Veteran care.
Factors Influencing Rural Hospitals to Participate and Remain in Accountable Care Organizations.
Lawton EJ, McCarty J, Vaughn TE … +2 more , Ullrich F, Mueller KJ
J Rural Health · 2026 Mar · PMID 42268668 · Full text
PURPOSE: Little is known about factors driving rural providers-who face unique challenges-to participate and remain in accountable care organization models. The purpose of this study was to investigate the specific facto...
PURPOSE: Little is known about factors driving rural providers-who face unique challenges-to participate and remain in accountable care organization models. The purpose of this study was to investigate the specific factors that rural hospitals evaluate when weighing both initial and continued participation in Medicare as well as commercial ACO models. Furthermore, we explored policy implications to improve ACO models' capacity to attract, retain, and promote success of rural providers. METHODS: Semistructured, in-depth interviews were conducted with rural hospital executives with direct knowledge of ACO agreement terms and factors driving ACO participation. The interview guide contained seventeen open-ended questions. Interviews were recorded, transcribed, coded using codebooks informed by the interview guide, and analyzed using a thematic analysis approach. FINDINGS: Interviewees identified five primary multi-faceted motivations for participation: (1) financial incentives-shared savings, upside-only risk initially, and upfront funding for some providers, (2) getting ahead of the curve of the move to value-based reimbursement, (3) importance placed on capacity to push toward improving population health or quality, (4) additional forms of resource gain, and (5) key outside factors. The specific ACO design affects rural providers' decision-making on timing and selection of particular models. Importantly for future policy development, multiple respondents raised concerns about moving to risk in ACO models, leading them to consider dropping out. CONCLUSIONS: Findings from this qualitative study provide an in-depth understanding that is vital to achieving CMS's goal of increasing participation in value-based care. In turn, this could further improve health care quality for countless lives.
Cultivating the Field of Rural Health Research: The Case for Rural Health Research Competencies.
Caloudas AB, Govier D, Arredondo K … +4 more , Yamada M, Coleman SRM, Hawkins K, Howren MB
J Rural Health · 2026 Mar · PMID 42268664 · Publisher ↗
PURPOSE: Rural Veterans face unique healthcare barriers and challenges despite an increased need for care. The U.S. Department of Veterans Affairs (VA) has long invested in research to improve Veteran health and healthca...
PURPOSE: Rural Veterans face unique healthcare barriers and challenges despite an increased need for care. The U.S. Department of Veterans Affairs (VA) has long invested in research to improve Veteran health and healthcare delivery; however, rural Veterans remain underrepresented in research, limiting the equitable translation of evidence into rural settings. Rural-specific research is, therefore, essential in improving rural Veterans' health. This commentary argues for the development of rural health research competencies and proposes possible competency domains to guide training, mentorship, and workforce development. METHOD: Drawing on existing rural health scholarship, competency-based education, and implementation science, we outline illustrative domains of competence relevant to conducting rigorous, ethical, and impactful rural health research. FINDING: There is currently no field-wide agreement on the knowledge, skills, and experiences that define a proficient rural health researcher. A core set of rural health research competencies is essential for defining effective rural health research practices, guiding the development, implementation, and evaluation of training efforts, and facilitating broader improvements in rural health research and healthcare. CONCLUSION: Establishing a flexible, evolving set of rural health research competencies, grounded in both academic rigor and community-embedded expertise, can strengthen the rural health research workforce, inform training and mentorship, and advance equitable healthcare for rural Veterans and rural populations more broadly.
"This Is What I Acquired in the Military, I Want to Keep It at the VA": Healthcare Perspectives and Preferences Among Rural American Indian/Alaska Native Women Veterans.
Good MK, Ball DD, Kramer BJ … +9 more , Davila H, Howren MB, Sadler A, Birdwell S, Culley M, Duncan V, Pawiki LH, Woodard K, Mengeling M
J Rural Health · 2026 Mar · PMID 42268654 · Publisher ↗
PURPOSE: American Indian and Alaska Native (AI/AN) women use VA healthcare and reside in rural areas at higher proportions than other women Veterans. To support an investigation of ways to improve healthcare access and o...
PURPOSE: American Indian and Alaska Native (AI/AN) women use VA healthcare and reside in rural areas at higher proportions than other women Veterans. To support an investigation of ways to improve healthcare access and outcomes among rural AI/AN women Veterans, we conducted listening sessions on healthcare experiences, needs, and preferences. METHODS: We conducted in-person, group interview-style listening sessions using a qualitative descriptive approach. Our sample was based on states with relatively high numbers of AI/AN women Veterans. Specific sites were identified in consultation with the VA Office of Tribal Government Relations. Eleven listening sessions were conducted in eight states. Sessions were audio-recorded, transcribed, coded, and analyzed with a thematic content approach. FINDINGS: Participants reported intentional decisions about choosing VA care for health conditions they considered a direct result of military service. Examples of reasons Veterans avoided using VA included preferences for culturally based treatment services and provider cultural awareness. The relative proximity of Indian Health Service/Tribal Health Program (IHS/THP) clinics compared to VA clinics was noted in decisions for primary and acute care needs. CONCLUSIONS: Aspects of women's prior military service were directly connected with present-day health concerns and choices about where to seek care. Results suggest AI/AN women actively select VA care for military-related conditions and use IHS/THPs for other health concerns. Healthcare systems should recognize this dual use as a Veteran-driven pattern and continue to strengthen care coordination across VA and IHS/THPs, building on existing efforts to support information sharing and continuity of care.
A Scoping Review of Inpatient Medical and Surgical Quality Outcomes at Critical Access Hospitals.
Aagaard KM, Bredbeck BC, Westfall JM … +5 more , Ringel M, Ibrahim AM, Dimick JB, Kaboli PJ, Mullens CL
J Rural Health · 2026 Mar · PMID 42252899 · Publisher ↗
PURPOSE: The landscape of rural health services is threatened with new federal health policies and ongoing hospital closures. Additionally, there is a lack of consensus about the quality of inpatient medical and surgical...
PURPOSE: The landscape of rural health services is threatened with new federal health policies and ongoing hospital closures. Additionally, there is a lack of consensus about the quality of inpatient medical and surgical services provided in rural critical access hospitals (CAHs). Information about quality of care at CAHs may be useful to guide policy decisions that affect their viability and to more cohesively understand outcomes for patients as rural hospital accessibility continues to change. METHODS: We performed a broad search across four medical literature databases for original research articles examining at least one patient quality outcome (e.g., complications, mortality, transfers, or readmissions) in the setting of inpatient care at CAHs. A qualitative analysis generated themes about the quality of care at CAHs. FINDINGS: Our search generated 3128 citations. After screening and full text review, 22 studies (17 original, 5 gray literature reports) were included in our analysis. Studies supported that CAH quality outcomes were equivalent or better than non-CAHs for many common surgical procedures, but there was less agreement about the quality of inpatient medical care provided at CAHs. Treat or transfer decisions, longitudinal change, and health policy are discussed to better contextualize these trends. CONCLUSIONS: The literature regarding quality of care at CAHs presents heterogeneous findings that must be contextualized by patient and study characteristics, longitudinal change, and policy. For selected common inpatient surgeries performed at CAHs, observational evidence suggests comparable short-term mortality and complication rates, in the context of existing case selection and transfer practices.
Integration of the Clinical Pharmacist Practitioner to Improve Rural Veteran Access and Quality for Chronic Obstructive Pulmonary Disease in Primary Care.
McFarland MS, Will S, Steiger-Chadwick R … +6 more , Portillo EC, Do S, Maskey P, Hetzel S, Ray C, Tran M
J Rural Health · 2026 Mar · PMID 42240108 · Publisher ↗
PURPOSE: Utilization of the clinical pharmacist practitioner (CPP) providing comprehensive medication management (CMM) has been shown to improve the quadruple aim of healthcare. Unfortunately, rural Veterans often lack a...
PURPOSE: Utilization of the clinical pharmacist practitioner (CPP) providing comprehensive medication management (CMM) has been shown to improve the quadruple aim of healthcare. Unfortunately, rural Veterans often lack access to the expertise of CPP, leading to differences in the quality of care provided as compared to non-rural Veterans. We explored the integration of CPP providing CMM as part of a partnership with the Office of Rural Health funded enterprise-wide initiative. Facilities trained, integrated, and measured CPP regarding quality of care and access to care in a rural Veteran initiative-the Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE). METHODS: Twenty-two primary care CPP at 17 facilities were trained focusing on COPD management in addition to CMM. All data and reports were extracted and derived from the VA Corporate Data Warehouse (CDW). For measurement of access, we evaluated the number of Veterans served as well as the number of total encounters performed, and the modality of care provided by the CPP. The overall percentage of Veterans noted as "rural" was also tracked. The percentage of patients that were seen by a primary care provider or CPP within 30, 60, and 90 days of ED or inpatient discharge were compared for those referred to and not referred to the COPD CARE program. Evaluation of quality adherence metrics, based on guideline directed therapy, compared the CPP COPD managed population to all Veterans with COPD. FINDINGS: From October 2022 through September 2024, COPD CARE CPP performed 71,520 encounters in 21,168 Veterans with a total program rurality of 70.8%. The percentage of patients that were seen by a primary care provider or CPP within 30, 60, and 90 days of ED or inpatient discharge were consistently higher for those referred to the COPD CARE program versus those who were not. By 90 days, 81.7% of those referred were seen versus 53.2% of those not referred. In the 2 years following hiring of primary care CPPs, 7 of the 10 best practices were delivered on over 90% of visits, where 5 of those best practices were delivered on over 99% of visits. CONCLUSION: This study demonstrated improved access and improved guideline directed therapy outcomes for rural Veterans seen by a CPP. Integration of the CPP with a focus on the management of COPD can increase access to CMM and increase overall quality.
Association Between Well-Being and Occupational Class in Small Businesses in the Rural United States.
Adhikari LD, Wagle S, Katare B
J Rural Health · 2026 Mar · PMID 42240085 · Publisher ↗
PURPOSE: To examine the possible differences in psychological distress, depressive symptoms, level of stress, productivity, and anxiety among employees in blue-collar and white-collar occupational settings of small busin...
PURPOSE: To examine the possible differences in psychological distress, depressive symptoms, level of stress, productivity, and anxiety among employees in blue-collar and white-collar occupational settings of small businesses in rural areas of the United States. METHODS: Cross-sectional surveys were employed. Data were collected in 2024 from 1910 employees aged 18 years or older working in rural small businesses across the 48 contiguous US states, randomly selected from the panel maintained by the online survey company. Multiple linear regression and a linear probability model were used to assess the association between occupational class and employees' mental well-being. FINDINGS: Employees in the blue-collar industry reported more frequent depressive symptoms (0.212, p < 0.01) and a higher level of anxiety before work (0.994, p < 0.01). Employees in the white-collar industry had a 7.9% higher probability of having work-related stress. However, no significant differences were observed in psychological distress, productivity, or work anxiety among employees in both blue-collar and white-collar industries. Demographic disparities were also observed in both occupational classes. Older employees were more productive. Work-related stress and anxiety were also significantly lower among older employees (50 to 64 years old and above). Female employees experienced depressive symptoms more frequently in blue-collar industries and reported greater work stress in white-collar industries. CONCLUSION: Occupational classes often shape employees' work perceptions, influencing their productivity and overall well-being. Understanding these class-based differences is essential to promoting employee well-being in rural small business settings in the United States.
Post-Intensive Care Fragmentation Among Rural Veterans: Transitions Between VA and Community Health Systems.
Hahn Z, Tyler B, Atwood C … +2 more , Hotchkiss JR, Mayr FB
J Rural Health · 2026 Mar · PMID 42233317 · Publisher ↗
PURPOSE: To evaluate how rural residence and health system transitions (between Veterans Affairs [VA] and community care) influence outpatient care fragmentation and clinical outcomes among Veterans following intensive c...
PURPOSE: To evaluate how rural residence and health system transitions (between Veterans Affairs [VA] and community care) influence outpatient care fragmentation and clinical outcomes among Veterans following intensive care unit (ICU) hospitalization. METHODS: We conducted a retrospective cohort study of 80,884 Veterans hospitalized with critical illness between January 1, 2019 and December 31, 2024. Using VA Corporate Data Warehouse records linked with community care claims, we calculated within-person changes in outpatient fragmentation using the modified Continuity of Care Index (mCOCI) for the 12 months before and after ICU discharge. We used multivariable linear regression and Fine-Gray competing risk models to assess the relationship between rurality, system engagement, and 30/90-day clinical outcomes. FINDINGS: Among the cohort (38% rural; mean age 69), adjusted mCOCI increased by 0.04 (95% CI, 0.03, 0.06; p < 0.001) post-discharge and the mean number of provider visits increased by 4.1 (95% CI 3.6, 4.5, p < 0.001), indicating significantly greater care fragmentation and care utilization. Neither higher VA engagement nor rurality were associated with changes in fragmentation, however, telehealth utilization was associated with a modest reduction in fragmentation. Compared to urban Veterans, rural Veterans had lower 30-day absolute probabilities of primary care follow-up (12.7% vs. 14.4%; RD -1.7%) and ED visits, yet faced higher rates of hospital readmission (16.1% vs. 15.0%; RD 1.0%) and a minimally higher probability of death (0.15% vs. 0.14%). All trends persisted and differences increased at 90 days. CONCLUSIONS: Recovery after critical illness is marked by a substantial escalation in care fragmentation and care utilization. Compared to urban counterparts, rural veterans faced worse outcomes, but no difference in fragmentation. Telehealth offered a substantial protective effect, that may also reduce the higher travel burden faced by rural veterans. These findings emphasize the need for integrated, rural-specific care models that leverage telehealth and cross-system coordination to support high-risk ICU survivors.
Connecting Rural Veterans: Community-Based Peer Social Interventions to Advance Health and Resource Access.
Gorman JA, Grigorian HL, Stevenson BJ … +6 more , Pugh KE, Kaubrys MM, Leeman MA, Kane MI, Sinclair LB, Bewsey K
J Rural Health · 2026 Mar · PMID 42220317 · Full text
PURPOSE: Rural veterans experience significant barriers to support, including social isolation and limited access to mental health services, resulting in elevated health risks compared to urban veterans. Inadequate socia...
PURPOSE: Rural veterans experience significant barriers to support, including social isolation and limited access to mental health services, resulting in elevated health risks compared to urban veterans. Inadequate social support is a major obstacle to help-seeking during crises. This study describes the feasibility and preliminary effectiveness of a peer-driven, community-based Veterans Socials (VS) to enhance support networks and connect non-VA-enrolled rural veterans to a supportive, information-rich community environment. METHODS: In partnership with a VA Medical Center, six peer specialist-led social groups were established over 13 months to engage rural veterans in three states. This mixed-methods study utilized cross-sectional participant surveys (n = 23), semi-structured interviews (n = 8), and host-completed forms for each of the 199 VS for a total of 1008 nonexclusive attendee engagements with 121 unique attendees. The Bowen feasibility framework guided the assessment of acceptability, preliminary effectiveness, demand, practicality, and implementation. FINDINGS: VS averaged 5.07 veterans per event. VS reached key demographics, including veterans not engaged in VA healthcare (22%; n = 5) and those at high-risk for isolation or loneliness (57%; n = 13). Preliminary effectiveness was achieved with 65% (n = 15) of participants reporting new friendships. All benchmarks for preliminary effectiveness (friend-making), practicality (independent operation without a VA employee), and implementation fidelity were met. Most acceptability and demand benchmarks were achieved, though two of six VS did not achieve the attendance criterion. CONCLUSIONS: Peer-led, community-based interventions are feasible in rural areas and can effectively reach veterans at risk for isolation and loneliness. Sustaining such efforts may rely on mobilizing and building community capacity, making peer-driven models a promising strategy for improving health outcomes for rural veterans.
Single-Day Couples Intervention for Veterans and Their Romantic Partners: A Pilot Feasibility Trial.
Dindo L, Donis N, Cramer M … +5 more , Boykin D, Rodrigues M, Woods K, Shanahan ML, Roddy MK
J Rural Health · 2026 Mar · PMID 42175859 · Publisher ↗
PURPOSE: Separation and divorce are associated with deterioration of mental and physical health. Veterans are >60% more likely to experience separation/divorce compared to non-Veterans. Access to couple-based treatment i...
PURPOSE: Separation and divorce are associated with deterioration of mental and physical health. Veterans are >60% more likely to experience separation/divorce compared to non-Veterans. Access to couple-based treatment is limited due to shortage of trained therapists, high costs, travel burdens, and stigma-challenges commonly exacerbated in rural settings. METHODS: This study assessed the feasibility, acceptability, and preliminary efficacy of a single-day, 6-h group workshop delivered virtually for rural Veterans and their romantic partners. The goal was to improve relationship quality and expand care access. Veterans and their partners completed measures of individual and relationship functioning before and 3 months post-workshop. Qualitative interviews were conducted 3 months post-workshop. FINDINGS: A total of 62 Veteran-partner couples participated (42% rural). Workshop completion (98%) and retention at the 3-month follow-up for Veterans (90%) and partners (79%) were high. Qualitatively, participants found the workshop helpful, engaging, and interactive. Many reported applying learned communication skills, viewed the workshop as a catalyst for improving their relationship, and said they would recommend it to others. From pre-workshop to 3 months post-workshop, Veterans reported reductions in trauma-related symptoms (ES = -0.23) and improvements in mental health functioning (ES = 0.22). Partners also showed improvements in overall functioning (ES = 0.27). No changes in relationship satisfaction were observed. CONCLUSIONS: The workshop was feasible to implement and well-received by Veterans and their partners. Preliminary outcomes suggest the intervention may be effective in improving individual well-being. Single-day group workshops-particularly when delivered via telehealth-hold promise as a scalable approach to increase access to relationship support for rural Veterans.
How Do Changes in Medicare Reimbursement for Mental Health Services Impact Access for Rural Older Adults?
Oster NV, Andrilla CHA, Patterson DG … +2 more , Burchim S, Graves JM
J Rural Health · 2026 Mar · PMID 42163779 · Publisher ↗
PURPOSE: In January 2024, new reimbursement policies took effect, allowing marriage and family therapists (MFTs) and mental health counselors (MHCs) to independently bill Medicare for diagnostic and mental health treatme...
PURPOSE: In January 2024, new reimbursement policies took effect, allowing marriage and family therapists (MFTs) and mental health counselors (MHCs) to independently bill Medicare for diagnostic and mental health treatment services. We sought to understand how and whether these policy changes have impacted access to mental health services among rural Medicare beneficiaries. METHODS: We conducted interviews with leaders of rural health systems and relevant mental health organizations regarding perceptions about Medicare reimbursement for MFTs and MHCs and the potential impact on access to rural mental health services. We screened and recruited 14 participants for 45 to 60 min individual interviews in July and August 2024. We used directed thematic analysis to develop and iteratively refine themes, identifying patterns in participant responses. FINDINGS: Interviewees generally felt that expanding the pool of mental health providers recognized by Medicare would improve the access and quality of mental health services among rural Medicare beneficiaries. However, interviewees frequently described workforce shortages, the chronic difficulty of hiring mental health providers in rural areas, and low Medicare reimbursement rates as challenges that may limit the policy's effectiveness. CONCLUSION: The inclusion of MFTs and MHCs in Medicare reimbursement policies may represent a meaningful advancement in expanding rural access to mental health services. Workforce shortages and reimbursement challenges may inhibit the policy's potential impact.
Rural-Urban Differences in the Incorporation of Workforce Planning and Development in the Strategic Planning Process of US Hospitals.
Apenteng BA, Opoku ST, Anokye-Mensah S … +5 more , Puobebe C, Boakye KG, Kimsey L, Peden AH, Owens CF
J Rural Health · 2026 Mar · PMID 42163775 · Publisher ↗
BACKGROUND: The effectiveness of healthcare systems relies on how well workforce planning and development strategies align with organizational goals, given the detrimental impact of workforce shortages on patient safety...
BACKGROUND: The effectiveness of healthcare systems relies on how well workforce planning and development strategies align with organizational goals, given the detrimental impact of workforce shortages on patient safety and healthcare quality. This study examines the determinants and rural-urban differences in the integration of workforce planning and development into strategic planning in US hospitals. METHODS: Data for this study were obtained from the 2022 American Hospital Association Annual Survey and the 2021 Medicare Hospital Cost Report. The study outcome was measured with a composite score, calculated as the count of workforce planning and development activities incorporated into strategic planning. A Poisson regression analysis was conducted to identify the determinants of strategically aligned workforce planning and development, and to assess rural-urban differences. RESULTS: Of the 2749 hospitals analyzed, most were urban, non-profit, and system-affiliated, with an average of 170 beds. Factors such as system affiliation and organizational size were positively linked to the incorporation of workforce planning into hospitals' strategic planning efforts. Conversely, for-profit ownership, critical access hospitals, and locations in the South were associated with less integration of workforce planning and development into strategic planning. CONCLUSION: Structural, institutional, and regional factors may influence the extent to which hospitals incorporate workforce planning and development in their strategic planning processes. Efforts to align workforce planning and development with strategic planning across US hospitals may require interventions to enhance institutional capacity and foster a culture of long-term planning for sustainability.
Differential Impact of the Supportive Services for Veteran Families (SSVF) Program on Veterans Affairs Healthcare Utilization and Costs Among Rural and Urban Veterans Experiencing Housing Instability.
Yoo M, Chapman AB, Suo Y … +3 more , Byrne T, Montgomery AE, Nelson RE
J Rural Health · 2026 Mar · PMID 42153335 · Full text
PURPOSE: This study examined whether the Supportive Services for Veteran Families (SSVF) program has a differential impact on healthcare utilization and costs among rural and urban Veterans experiencing housing instabili...
PURPOSE: This study examined whether the Supportive Services for Veteran Families (SSVF) program has a differential impact on healthcare utilization and costs among rural and urban Veterans experiencing housing instability. Understanding geographic variation in program effects is important for guiding implementation and resource allocation within the Veterans Affairs (VA) healthcare system. METHODS: We conducted a retrospective cohort study using national VA administrative data from October 1, 2018 to September 30, 2023. Veterans were classified as SSVF participants or eligible non-SSVF Veterans based on indicators of housing instability. A target trial emulation framework with inverse probability weighting was used to adjust for baseline differences. Rurality was defined using Rural-Urban Commuting Area codes applied to Veterans' residential addresses recorded in VA administrative data. Weighted longitudinal models estimated quarterly changes in healthcare utilization and costs and tested whether effects varied by rurality. FINDINGS: SSVF enrollment was associated with reductions in inpatient utilization and costs and modest increases in outpatient visits, resulting in overall decreases in total VA healthcare costs. Emergency department use showed small reductions among urban Veterans and little measurable change among rural Veterans. Overall patterns of healthcare utilization and spending were similar across rural and urban Veterans, and statistical tests did not indicate significant rural-urban differences in SSVF effects. CONCLUSIONS: SSVF participation was associated with shifts away from inpatient care and toward greater outpatient engagement among Veterans experiencing housing instability. These patterns were observed among both rural and urban Veterans, suggesting that the healthcare benefits of housing stabilization programs are similar across geographic settings.
Environmental Supports, Expectations, and Barriers to Leisure-Time Physical Activity During Pregnancy: A Rural-Urban Comparison.
Rogers CW, Crisp A, Wilhite K … +7 more , Thrower A, Marshall E, Marrero-Rivera JP, Gallagher JB, Gibbs BB, Whitaker KM, Ross SET
J Rural Health · 2026 Mar · PMID 42135935 · Full text
BACKGROUND: Physical activity (PA) during pregnancy has well-documented benefits, yet pregnant rural residents may face additional barriers to PA. OBJECTIVE: To examine whether leisure-time physical activity (LTPA) and c...
BACKGROUND: Physical activity (PA) during pregnancy has well-documented benefits, yet pregnant rural residents may face additional barriers to PA. OBJECTIVE: To examine whether leisure-time physical activity (LTPA) and correlates of LTPA, including exercise outcome expectations, barriers, and environmental supports for PA, differ by rurality, and explore whether rurality moderates the associations between these correlates and LTPA during pregnancy. METHODS: Pregnant individuals from Iowa and West Virginia (n = 374) completed questionnaires assessing LTPA, exercise outcome expectations and barriers during each trimester, and environmental supports for PA at the first trimester. Rurality status was categorized as urban, micropolitan, or small town rural using Rural-Urban Commuting Area codes. Robust linear mixed effects models included trimester as a fixed effect and a random intercept for participant. Environmental supports were analyzed using a robust linear model restricted to first-trimester data. Models were adjusted for site, age, pre-pregnancy body mass index, education, parity, and minority status. RESULTS: In unadjusted models, small-town rural participants engaged in less LTPA than urban participants (9.02 vs. 12.14 MET-h/week, p = 0.021), though this was not significant after adjustment. Small-town rural participants reported fewer environmental supports for PA than urban participants (β = -0.42 SD, p = 0.002). Rurality did not moderate the associations between examined correlates and LTPA. CONCLUSIONS: Rurality was not associated with LTPA, exercise expectations, or barriers after adjustment. Although small-town rural participants reported fewer environmental supports for PA, this was not associated with LTPA, warranting further investigation in larger samples to determine whether improving environmental supports would translate into increased LTPA during pregnancy.
Economic Stability of Children, a Key Social Determinant of Health, in the United States: Differences by Rurality.
Crouch E, Boswell E, Odahowski C … +4 more , Benavidez G, Bennett K, Hung P, Nelson J
J Rural Health · 2026 Mar · PMID 42117331 · Full text
PURPOSE: This study aims to examine rural-urban differences in the prevalence of three measures of one domain of social determinants of heath, economic security, in a national sample of children. METHODS: This was a cros...
PURPOSE: This study aims to examine rural-urban differences in the prevalence of three measures of one domain of social determinants of heath, economic security, in a national sample of children. METHODS: This was a cross-sectional study (2022-2023) of the National Survey of Children's Health. Primary exposures included rurality and child and caregiver characteristics. Three economic stability outcomes were whether a child experienced housing instability, food insecurity, and/or income inadequacy (having a hard time getting by on family income). We used bivariate analyses and multivariable regressions analyses to examine the association between rurality and measures of economic stability. All analyses were weighted with survey sampling to generate nationally representative estimates. FINDINGS: In the weighted multivariable regression analysis, adjusting for child and caregiver characteristics, rural children had higher odds of housing instability (aOR 1.20; 95% CI 1.07-1.34), food insecurity (aOR 1.47; 95% CI 1.22-1.78), and income inadequacy (aOR 1.32; 95% CI 1.18-1.48), compared to urban children. CONCLUSIONS: Rural children and their families are experiencing everyday challenges in housing, food access, and the ability to get by on their income, which are all shown to have ramifications on their health. Child advocates, policymakers, and program developers must consider these factors when developing programs and policies for families residing in rural America.
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