Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC.
Med Care. 2018 Oct;56(10):870-876. doi: 10.1097/MLR.0000000000000973.
The complex nature of managing care for people with severe mental illness (SMI), including major depression, bipolar disorder, and schizophrenia, is a challenge for primary care practices, especially in rural areas. The team-based emphasis of medical homes may act as an important facilitator to help reduce observed rural-urban differences in care.
The objective of this study was to examine whether enrollment in medical homes improved care in rural versus urban settings for people with SMI.
Secondary data analysis of North Carolina Medicaid claims from 2004-2007, using propensity score weights and generalized estimating equations to assess differences between urban, nonmetropolitan urban and rural areas.
Medicaid-enrolled adults with diagnoses of major depressive disorder, bipolar disorder or schizophrenia. Medicare/Medicaid dual eligibles were excluded.
We examined utilization measures of primary care use, specialty mental health use, inpatient hospitalizations, and emergency department use and medication adherence.
Rural medical home enrollees generally had higher primary care use and medication adherence than rural nonmedical home enrollees. Rural medical home enrollees had fewer primary care visits than urban medical home enrollees, but both groups were similar on the other outcome measures. These findings varied somewhat by SMI diagnosis.
Findings indicate that enrollment in medical homes among rural Medicaid beneficiaries holds the promise of reducing rural-urban differences in care. Both urban and rural medical homes may benefit from targeted resources to help close the remaining gaps and to improve the success of the medical home model in addressing the health care needs of people with SMI.
管理严重精神疾病（SMI）患者的医疗护理，包括重度抑郁症、双相情感障碍和精神分裂症，具有复杂性，这对基层医疗实践来说是一个挑战，尤其是在农村地区。医疗之家的团队式重点可能是一个重要的促进因素，可以帮助缩小观察到的农村与城市地区之间的护理差异。
本研究旨在检验医疗之家的参与是否改善了农村和城市环境中 SMI 患者的护理。
利用倾向评分权重和广义估计方程，对 2004-2007 年北卡罗来纳州医疗补助数据进行二次数据分析，以评估城市、非大都市城市和农村地区之间的差异。
患有重度抑郁症、双相情感障碍或精神分裂症诊断的医疗补助计划参保成年人。排除医疗保险/医疗补助双重资格者。
我们检查了初级保健使用、精神科专科使用、住院治疗和急诊使用以及药物依从性等利用指标。
农村医疗之家的参保者通常比农村非医疗之家的参保者有更高的初级保健使用和药物依从性。农村医疗之家的参保者接受的初级保健就诊次数少于城市医疗之家的参保者，但两组在其他结果指标上相似。这些发现因 SMI 诊断而有所不同。
这些发现表明，农村医疗补助计划参保者参与医疗之家有望缩小农村与城市地区之间的护理差异。城市和农村医疗之家都可能受益于有针对性的资源，以帮助缩小剩余差距，并提高医疗之家模式在满足 SMI 患者医疗需求方面的成功。
