National Academy of Sciences, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001, Institute of Medicine.Google Scholar

Institute for Healthcare Improvement, “The Triple Aim,” Institute for Healthcare Improvement, available at <http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

See National Academy of Sciences, supra note 1; see also McCarthy, D. and Klein, S., “The Triple Aim Journey: Improving Population Health and Patients’ Experience of Care, While Reducing Costs. Case Study,” Commonwealth Fund pub. 1421, vol. 48, July 2010, New York and Washington, D.C.; Documents prepared by the Institute of Medicine Committee on the Quality of Health Care in America summarize recommendations made for improvement with specific suggestions for operationalization. This summary was prepared by the ACMQ (American College of Medical Quality) Medical Informatics Program, available at <http://www.acmq.org/education/iomsummary.pdf> (last visited March 4, 2011).Google Scholar

Vincent, G. K. and Velkoff, V. A., “The Next Four Decades - The Older Population in the United States: 2010–2050,” U.S. Census Bureau, U.S. Department of Commerce/Economics and Statistics Administration P25–1138 issued May 2010, available at <http://www.census.gov/prod/2010pubs/p25–1138.pdf> (last visited March 3, 2011).Google Scholar

Parekh, A. K. and Barton, M. B., “The Challenge of Comorbidity for the US Health Care System,” JAMA 303, no. 13 (2010): 1303–1304.CrossRefGoogle Scholar

Wise, P. H., “The Transformation of Child Health in the United States,” Health Affairs 23, no. 5 (2004): 9–25; see also Shore, R. and Shore, B., “Kids Count Indicator Brief: Reducing the Child Death Rate,” Annie Casey Foundation, Baltimore Maryland, available at <http://www.aecf.org/KnowledgeCenter/Health.aspx> (last visited March 3, 2011).Google Scholar

See National Academy of Sciences, supra note 1; Wennberg, J. E., Fisher, E. S., Goodman, D. C., and Skinner, J. S., Tracking the Care of Patients with Severe Chronic Illness, Dartmouth Atlas of Healthcare, 2008, available at <http://www.dartmouthatlas.org/downloads/atlases/2008_Chronic_Care_Atlas.pdf> (last visited March 3, 2011).Google Scholar

Lynne, J., “Sick to Death, Reforming Health Care for the Last Years of Life,” From the Bookshelves special interview series, Kaiser Family Foundation, August 4, 2005, available at <http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1488> (last visited March 3, 2011).Google Scholar

U.S. Department of Health & Human Services Interagency Workgroup on Multiple Chronic Conditions, A Strategic Framework (draft), May 2010, Washington, D.C., available at <http://www.hhs.gov/ash/initiatives/mcc/federal-register051410.pdf> (last visited February 3, 2011); see also Ombudsman News, “Chronic Medical Conditions,” available at <http://www.financial-ombudsman.org.uk/publications/ombudsman-news/1/chronic-medical-conditions.htm> (last visited March 3, 2011); O'Halloran, J. F., Miller, G. C., and Britt, H., “Defining Chronic Conditions for Primary Care with ICPC-2,” Family Practice 21, no. 4 (2004): 381–386; Medline Plus Medical Encyclopedia, “Acute Versus Chronic Conditions,” U.S National Library of Medicine and National Institutes of Health, available at <http://www.nlm.nih.gov/medlineplus/ency/imagepages/18126.htm> (last visited March 3, 2011).CrossRefGoogle Scholar

Institute for Healthcare Improvement, “Chronic Conditions,” available at <http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WebACTIONCoordinatingCareforPatientswithComplexNeeds.htm> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Centers for Disease Control and Prevention, “Chronic Disease Overview: Costs of Chronic Disease,” available at <http://www.cdc.gov/nccdphp/overview.htm> (last visited March 3, 2011); Cutler, D. M., Rosen, A. B., and Vijan, S., “The Value of Medical Spending in the United States, 1960–2000,” New England Journal of Medicine 355, no. 9 (2006): 920–927; see also Wennberg, J. E., Fisher, E. S., Sharp, S. M., and McAndrew, M., The Care of Patients with Severe Chronic Illness, report of the Medicare Program by the Dartmouth Atlas Project, the Center for the Evaluative Clinical Sciences, and Dartmouth Medical School, available at <http://www.dartmouthatlas.org/downloads/atlases/2006_Chronic_Care_Atlas.pdf> (last visited March 3, 2011).CrossRefGoogle Scholar

Bodenheimer, T., Chen, E., and Bennett, H. D., “Confronting the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do the Job?” Health Affairs 28, no. 1 (2009): 64–74; see also Wennberg, et al., supra note 7.CrossRefGoogle Scholar

McKinney, M., “Quality, Not Quantity,” Modern Healthcare 40, no. 42 (2010): 8–9.Google Scholar

Institute of Medicine, “The Healthcare Imperative: Lowering Costs and Improving Outcomes. Workshop Summary,” available at <http://iom.edu/Reports/2011/The-Healthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx> (last visited August 12, 2010).+(last+visited+August+12,+2010).>Google Scholar

Meier, D. E., Casarett, D. J., von Gunten, C. F., Smith, W. J., and Storey, C. P., “Palliative Medicine: Politics and Policy,” Journal of Palliative Medicine 13, no. 2 (2010): 1–6.CrossRefGoogle Scholar

Brady, D. and Kessler, D., “Uncommon Knowledge: Healthcare and President Obama and Politics,” Hoover Institute/Stanford University, available at <http://www.hoover.org/multimedia/uncommonknowledge/26724> (last visited August 8, 2010).Google Scholar

Steuerle, E. C., “Dealing with the Original Sin Driving Health Costs,” The Government We Deserve Commentaries, The Urban Institute, July 7, 2008, available at <http://www.urban.org/publications/901183.html> (last visited August 8, 2010); Unreimbursed costs must be accounted for in the budgetary framework – the shifting of these is a factor in the cost increase for other services that are reimbursed; see also Brownlee, S., Overtreated (New York: Bloomsbury USA, 2007): At 2–6; Fisher, E. S., Wennberg, D. E., Stukel, T. A., Gottlieb, D. J., Lucas, F. L., and 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): 273–287.Google Scholar

Money Driven Medicine, directed by Gibney, A., California Newsreel, 2009.Google Scholar

Fisher, E. S., Goodman, D., Skinner, J., and Bronner, K. K., “Health Care Spending, Quality & Outcomes,” Dartmouth Atlas Project Topic Brief, February 27, 2009, available at <http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf> (last visited March 3, 2011); see also Fisher, et al., supra note 17.+(last+visited+March+3,+2011);+see+also+Fisher,+et+al.,+supra+note+17.>Google Scholar

See Parekh, and Barton, , supra note 5.Google Scholar

Tilden, V. P. and Thompson, S. T., “Policy Issues in End-of-Life Care,” Journal of Professional Nursing 25, no. 6 (2009): 363–368, at 363.CrossRefGoogle Scholar

Crippen, D. W., ‘Afterword’ in End of Life Communication in the ICU (New York: Springer, 2008): 167–169.10.1007/978-0-387-72966-4CrossRefGoogle Scholar

Himmelstein, D. U., Thorne, D., Warren, E., and Woolhandler, S., “Medical Bankruptcy in the United States, 2007: Results of a National Study,” American Journal of Medicine 122, no. 8 (2009): 741–746.CrossRefGoogle Scholar

U.S. Department of Health and Human Services, The CAHPS Improvement Guide/Shared Decision Making, Agency for Healthcare Research and Quality, available at <http://www.cahps.ahrq.gov/qiguide/content/interventions/SharedDecisionMaking.aspx> (last visited March 3, 2011); see also Wennberg, J. E., Brownlee, S., Fisher, E. S., Skinner, J. S., and Weinstein, J. N., “Expanding Coverage without Increasing Health Care Spending: Dartmouth Institute White Paper Recommends Course for the Obama Administration,” December 17, 2008, available at <http://www.dartmouthatlas.org/downloads/reports/agenda_for_change.pdf> (last visited March 3, 2011).+(last+visited+March+3,+2011);+see+also+Wennberg,+J.+E.,+Brownlee,+S.,+Fisher,+E.+S.,+Skinner,+J.+S.,+and+Weinstein,+J.+N.,+“Expanding+Coverage+without+Increasing+Health+Care+Spending:+Dartmouth+Institute+White+Paper+Recommends+Course+for+the+Obama+Administration,”+December+17,+2008,+available+at++(last+visited+March+3,+2011).>Google Scholar

Teno, J. M., Clarridge, B. R., Casey, V., Welch, L. C., Wetle, T., Shield, R., and Mor, V., “Family Perspectives on End-of-Life Care at the Last Place of Care,” JAMA 291, no. 1 (2004): 88–93; see also Christakis, N. A. and Iwashyna, T. J., “Attitude and Self-Reported Practice Regarding Prognostication in a National Sample of Internists,” Archives of Internal Medicine 158, no. 21 (1998): 2389–2395.CrossRefGoogle Scholar

Gawande, A., “Letting Go,” The New Yorker, August 2, 2010, available at <http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

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). (last visited March 3, 2011).' href=https://scholar.google.com/scholar?q=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++(last+visited+March+3,+2011).>Google Scholar

Cromartie, J. and Bucholtz, S., “Defining the ‘Rural’ in Rural America,” Amber Waves, June 2008, available at <http://www.ers.usda.gov/AmberWaves/June08/Features/RuralAmerica.htm> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

U.S. Department of Health and Human Services, “National Healthcare Disparities Report,” Agency for Healthcare Research and Quality, available at <www.ahrq.gov/qual/qrdr09.htm> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Stewart, K. and Sanders, D. N., “Aging and Disability Resources Center,” Grant submitted to the Department of Aging and Disability Services, State of Texas, 2009.Google Scholar

Grantmakers in Health, Rural Health Care: Innovations in Policy and Practice, Issue Brief no. 34, 2009, available at <http://www.gih.org/usr_doc/Rural_Health_Care_March_2009.pdf> (last visited October 12, 2010).+(last+visited+October+12,+2010).>Google Scholar

Jones, C. A., Parker, T. S., Ahearn, M., Mishra, A. K., and Variyam, J. N., ERS/USDA Briefing Room, Rural Income, Poverty, and Welfare: Income and Nonfarm Earnings, available at <http://www.ers.usda.gov/Briefing/IncomePovertyWelfare/> (last visited September 21, 2010).+(last+visited+September+21,+2010).>Google Scholar

Blumenthal, S. J., “The Effect of Socioeconomic Status on Health in Rural and Urban America,” JAMA 287, no.1 (2002): 109.CrossRefGoogle Scholar

Agency for Healthcare Research and Quality (AHRQ), “Improving Health Care for Rural Populations,” U.S. Department of Health & Human Services, available at <http://www.ahrq.gov/research/rural.htm> (last accessed March 3, 2011).+(last+accessed+March+3,+2011).>Google Scholar

Roberts, L. W., Battaglia, J., Smithpeter, M., and Epstein, R. S., “An Office on Main Street,” Hastings Center Report 20, no. 4 (1999): 28–37; see also AHRQ, supra note 27.CrossRefGoogle Scholar

Id. (Roberts et al.).Google Scholar

Gamm, L., Hutchison, , and Bellamy, G., “Healthy People 2010: Identifying Rural Health Priorities and Models for Practice,” Journal of Rural Health 18, no. 1 (2002): 9–14.CrossRefGoogle Scholar

Marie Hall, F. Institute for Rural and Community Health, “Atlas of Rural & Community Health,” Texas Tech University Health Sciences Center, available at <http://www.ttuhsc.edu/rural-health/> (last visited March 3, 2011).Google Scholar

Heady, H. R., “A Delicate Balance: The Economics of Rural Healthcare Delivery,” JAMA 287, no. 1 (2002): 110.CrossRefGoogle Scholar

Institute of Medicine, “Retooling for an Aging America,” available at <http://www.iom.edu/~/media/Files/Report%20Files/2008/Retooling-for-an-Aging-AmericaBuilding-the-Health-CareWorkforce/RetoolingforanAgingAmericaBuildingtheHealthCareWorkforce.pdf> (last visited June 30, 2010); Coburn, A. F., Lundblad, J. P., MacKinney, A. C., McBride, T. D., and Mueller, K. J., The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A First Look. Rural Policy Research Institute, Robert Wood Johnson Foundation, available at <http://www.rupri.org/Forms/Health_PPACAImpacts_Sept2010.pdf> (last visited March 3, 2011).Google Scholar

Campbell, C. L., Merwin, E., and Yan, G., “Factors that Influence the Presence of a Hospice in a Rural Community,” Journal of Nursing Scholarship 41, no. 4 (2009): 420–428.CrossRefGoogle Scholar

Glover, J., “‘Doing’” Ethics in Rural Health Care Institutions,” in Nelson, W., ed., Handbook for Rural Health Care Ethics: A Practical Guide for Professionals (Hanover, NH: Dartmouth College, 2009): At 63; see Roberts, et al., supra note 35.Google Scholar

Gardent, P. and Reeves, S., “Ethics Conflicts in Rural Communities: Allocation of Scarce Resources,” in Nelson, (id.), at 164.Google Scholar

Niemira, D. and Townsend, T., “Ethics Conflicts in Rural Communities: End-of-Life Decision-Making,” in Nelson, (id.), at 209.Google Scholar

Federal Coordinating Council for Comparative Effectiveness Research, available at <http://www.hhs.gov/recovery/programs/os/cerbios.html> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Wennberg, J., Brownlee, S., Fisher, E., Skinner, J., and Weinstein, J., “Dartmouth Atlas Project,” Dartmouth Institute for Health Policy & Clinical Practice, available at <http://www.dartmouthatlas.org/downloads/reports/agenda_for_change.pdf=> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Zigmond, J., “Long-Term Fix,” Modern Healthcare 40, no. 42 (2010): 6–16.Google Scholar

Jacobson, G., Neuman, T., and Damico, A., Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long Term Care Facilities: A Potential for Achieving Medicare Savings and Improving the Quality of Care, Henry J. Kaiser Family Foundation, available at <http://www.kff.org/medicare/upload/8109.pdf> (last visited March 3, 2011).Google Scholar

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).+(last+visited+October+16,+2010).>Google Scholar

See Jacobsen, et al., supra note 48.Google Scholar

See Bodenheimer, et al., supra note 12.Google Scholar

Hutchison, L., Hawes, C., and Williams, L., “Access to Quality Health Services in Rural Areas – Long Term Care: A Literature Review,” Rural Healthy People 2010, no. 3 (2010): 1–28, available at <http://www.srph.tamhsc.edu/centers/rhp2010/Volume_3/Vol3Ch1LR.pdf> (last visited March 3, 2011).Google Scholar

Temel, J. S., Greer, J. A., and Muzikansky, A. et al., “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer,” New England Journal of Medicine 363, no. 8 (2010): 733–742; Field, M. J. and Cassel, C. K., Approaching Death: Improving Care at the End of Life, Report of the Institute of Medicine Task Force, National Academy, 1997, Washington, D.C., available at <http://www.cms.gov/manuals/downloads/clm104c11.pdf> (last visited March 3, 2011). The use of palliative care services remains low despite an increasing number of physicians trained and willing to deliver such care. See General Accounting Office (GAO), End of Life Care: Key Components Provided by Programs in Four States: Report to the Honorable Ron Wyden, U.S. Senate, December 2007.CrossRefGoogle Scholar

Kelley, A. S., Meier, D. E., “Palliative Care – a Shifting Paradigm,” New England Journal of Medicine 363, no. 8 (2010): 781–782.CrossRefGoogle Scholar

Wright, A., Keating, N. L., Balboni, T. A., Matulonis, U. A., Block, S. D., and Prigerson, H. G., “Place of Death: Correlations with Quality of Life of Patients with Cancer and Predictors of Bereaved Caregivers’ Mental Health,” Journal of Clinical Oncology September (2010): 4457–4464; National Cancer Policy Board, Institute of Medicine, Improving Palliative Care: We Can Take Better Care of People with Cancer, available at <http://www.nap.edu/catalog/10790.html> (last visited March 3, 2011); see Temel, et al., supra note 53.+(last+visited+March+3,+2011);+see+Temel,+et+al.,+supra+note+53.>Google Scholar

Van Vorst, R. F., Crane, L. A., Barton, P. L., Kutner, J. S., Kallail, J., and Westfall, J. M., “Barriers to Quality Care for Dying Patients in Rural Communities,” Journal of Rural Health 22, no. 3 (2006): 248–253.CrossRefGoogle Scholar

See Niemira, and Townsend, , supra note 44.Google Scholar

Middlewood, S., Gardner, G., and Gardner, A., “Dying in Hospital: Medical Failure or Natural Outcome?” Journal of Pain & Symptom Management 22, no. 6 (2001): 1035–1041.CrossRefGoogle Scholar

American Psychological Association, Issues of Access and Variability in Health Care at the End of Life, available at <http://www.apa.org/topics/death/end-of-life.aspx#> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

American Psychological Association Office of Rural Health Report, Caring for the Rural Community: An Interdisciplinary Curriculum, Washington, D.C., 1995.Google Scholar

Matthew, D. B., “Race, Religion, and Informed Consent - Lessons from Social Science,” Journal of Law, Medicine & Ethics, 36, no. 1 (2008): 150–173.CrossRefGoogle Scholar

National Institutes of Health, “National Institutes of Health State-of-the-Science Conference: Statement on Improving End-of-Life Care,” December 6–8, 2004, available at <http://consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm> (last visited March 4, 2011).+(last+visited+March+4,+2011).>Google Scholar

Ferrell, B. R. and Coyle, N., Textbook of Palliative Care (New York: Oxford University Press, 2001): At 3–5, 27–33.Google Scholar

See Campbell, et al., supra note 41.Google Scholar

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).Google Scholar

Virnig, B. A., Moscovice, I., Durham, S., and 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., and Roberts, L. W., “Barriers to Healthcare as Reported by Rural and Urban Interprofessional Providers,” Journal of Interprofessional Care 20, no. 2 (2006): 105 118.CrossRefGoogle Scholar

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

National Hospice and Palliative Care Organization, NHPCO Facts and Figures: Hospice Care in America, 2010, available at <http://www.ecommunity.com/homehealth/uploads/files/NHPCO_facts_and_figures.pdf> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

National Hospice and Palliative Care Organization, “National Summary of Hospice Care for 2009,” available at <http://www.nhpco.org/i4a/pages/index.cfm?pageid=5953> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Personal communication from Holly White to author [KEA] (October 25, 2010).Google Scholar

National Hospice and Palliative Care Organization, Hospice Care in America, 2010, available at <http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

Beasley, D. M., The 2010 Report to the Secretary: Rural Health and Human Service Issues, National Advisory Committee on Rural Health and Human Services, May 2010.Google Scholar

See Wennberg, et al., supra note 24; see also Beasley, (id.)Google Scholar

Coburn, A. F., Lundblad, J. P., McKinney, A. C., McBride, T. D., and Mueller, K. J., The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A First Look, prepared by the Rural Policy Research Institute, September 16, 2010.Google Scholar

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). (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 (last visited March 3, 2011).' href=https://scholar.google.com/scholar?q=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++(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++(last+visited+March+3,+2011).>Google Scholar

Ricketts, T. C., “Workforce Issues in Rural Areas: A Focus on Policy Equity,” American Journal of Public Health 95, no. 1 (2005): 42–48, at 44; see also Beasley, , supra note 72.CrossRefGoogle Scholar

See Beasley, , supra note 72.Google Scholar

Agency for Healthcare Research and Quality, “Improving Healthcare in Rural Populations,” available at <http://www.ahrq.gov/research/rural.htm> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

See Beasley, , supra note 72; see also Riley, K., Myers, W., and Schneeweis, R., “Recruiting Physicians to Rural Practice,” Western Journal of Medicine 155, no. 5 (1991): 500–504; Pepper, C. M., Sandefer, R. H., and Gray, M. J., “Recruiting and Retaining Physicians in very Rural Areas,” Journal of Rural Health 26, no. 2 (2010): 196–200.Google Scholar

McCartie, B., “Recruiting Physicians to Rural Areas,” Health Progress 85, no. 2 (2004): 34–35, and 53.Google Scholar

MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., and Hunsaker, M., “A National View of Rural Health Workforce Issues in the USA,” Rural and Remote Health 10 (2010): 1531.Google Scholar

See Beasley, , supra note 72; see also Hersh, W. R., Hickam, D. H., Severance, S. M., Dana, T. L., Krages, K. P., and Helfand, M., “Telemedicine for the Medicare Population: Update,” AHRQ Publication No. 06-E007 (February 2006); National Library of Medicine, “National Telemedicine Initiative,” available at <http://www.nlm.nih.gov/research/telemedinit.html (last visited March 3, 2011).Google Scholar

“More Seniors are Learning to Use Computer,” RedOrbit, Inc., March 14, 2008, available at <http://www.redorbit.com/news/technology/1295523/more_seniors_are_learning_to_use_computers/index.html> (last visited March 3, 2011).+(last+visited+March+3,+2011).>Google Scholar

“Broadband Internet Adoption and Use: Dial-Up versus Broadband Internet Use,” Broadband Internet's Value for Rural America, August 2009, available at <http://www.redorbit.com/news/technology/1295523/more_seniors_are_learning_to_use_computers/index.html> (last visited March 3, 2011). (last visited March 3, 2011).' href=https://scholar.google.com/scholar?q=“Broadband+Internet+Adoption+and+Use:+Dial-Up+versus+Broadband+Internet+Use,”+Broadband+Internet's+Value+for+Rural+America,+August+2009,+available+at++(last+visited+March+3,+2011).>Google Scholar

Schlairet, M. C., “End of Life Nursing Care: Statewide Survey of Nurses Education Needs & Effects of Education,” Journal of Professional Nursing 25, no. 3 (2009): 170–177; see also Domrose, C., “Coming of Age: New Geriatric Care Models and Technological Advances Offer Better Treatment Options,” 2010, available at <http://news.nurse.com/article/20101025/NATIONAL02/110250041/-1/frontpage> (last visited March 3, 2011) .CrossRefGoogle Scholar

Gamm, L. D., Hutchison, L. L., Dabney, B. J., Dorsey, A. M., eds., Rural Healthy People 2010: A Companion Document to Healthy People 2010, the Texas A&M University System Health Science Center, School of Rural Public Health, and Southwest Rural Health Research Center 1 (2003).Google Scholar

Wright, B., “Direct Care Workers in Long-Term Care,” AARP Public Policy Institute, 2005; see also Barry, T. et al., “Nurse Aide Empowerment Strategies and Staff Stability: Effects on Nursing Home Resident Outcomes,” Gerontologist 45, no. 3 (2005): 309–317.Google Scholar

Wilson, S. R., Strub, P., Buist, A. S., Knowles, S. B., Lavori, P. W., Lapidus, J., W. M. Vollmer, and the Better Outcomes of Asthma (Boat) Study Group, “Shared Treatment Decision Making Improves Adherence and Outcomes on Poorly Controlled Asthma,” American Journal of Respiratory and Critical Care Medicine 181, no. 6 (2010): 566–577; see also U.S. Department of Health and Human Services, supra note 24.CrossRefGoogle Scholar

Stamm, B., Lambert, D., Piland, N., and Speck, N., “A Rural Perspective on Healthcare for the Whole Person,” Professional Psychology: Research and Practice 38, no. 3 (2007): 298–304.CrossRefGoogle Scholar

Goodman, D. C., Fisher, E. S., Chang, C., Morden, N. E., Jacobson, J. O., Murray, K., Miesfeldt, S., and Bronner, K. K., ed., Quality End of life Cancer Care for Medicare Beneficiaries, a Report of the Dartmouth Atlas Project and Dartmouth Institute for Health Policy and Clinical Practice, November 16, 2010.Google Scholar

See Wennberg, et al., supra note 24.Google Scholar

See Wennberg, et al., supra note 7.Google Scholar

See Fisher, et al., supra note 19; see also Wennberg, et al., 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.Google Scholar

See Fisher, et al., supra note 19.Google Scholar

National Academies Press, “Quality through Collaboration: The Future of Rural Health,” Institute of Medicine, available at <http://iom.edu/Reports/2004/Quality-Through-Collaboration-The-Future-of-Rural-Health.aspx> (last visited September 28, 2010).+(last+visited+September+28,+2010).>Google Scholar

See Coburn, et al., supra note 74; see also Fisher, et al., supra note 19.Google Scholar

See Beasley, , supra note 72.Google Scholar

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

See Wennberg, et al., supra note 11, at 46.Google Scholar

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., and 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. and Benson, J. M., “Understanding How Americans View Healthcare Reform,” New England Journal of Medicine 361, no. 9 (2009): E13.CrossRefGoogle Scholar