Staff Publications

GRC is proud to support and sponsor publications related to our areas of expertise and specific to our projects. Please check this page periodically as we continue to complete publications and reports.




Applying the Urgent Maternal Warning Signs Initiative in a Novel Setting

Jenkins, Katherine; Quarshie, Evelyn; Phommasathit, Crystal; Menegay, Michelle; Lorenz, Allison; Schneider, Patrick; Oza-Frank, Reena; Haviland, Breanne; Kristofzski-Raizor, Heather; Gogan Turner, Dyane

Journal for Healthcare Quality

Symptoms of urgent maternal warning signs (UMWS) may occur during pregnancy or after delivery and may have lasting effects or indicate a life-threatening situation if left untreated. The state department of health sponsored a quality improvement project (QIP) to broaden the reach of UMWS education beyond traditional clinical settings, to public health settings where prenatal and postpartum women are seen. Specifically, the QIP implemented process changes to provide education (written and verbal) and resources to individuals receiving services from Women, Infants, and Children clinics during pregnancy and up to 12 weeks postpartum. Clinics submitted participant-level data although the Research Electronic Data Capture secure data portal. The key results indicated an increase in both written and verbal education. In addition, the project monitored referrals made specific to conditions identified through project-specific data collection and the provision of UMWS education.


A Prediction Model for Severe Maternal Morbidity and Mortality After Delivery Hospitalization

Frey, Heather A. MD; Ashmead, Robert PhD, Farmer, Alyssa PhD; Kim, Yoshie H. MS; Shellhaas, Cynthia MD, MPH; Oza-Frank, Reena PhD; Jackson, Rebecca D. MD; Costantine, Maged M. MD; Lynch, Courtney D. PhD, MPH

Obstetrics & Gynecology

A prediction model for SMM or mortality up to 1 year postpartum was created and internally validated with information available to health care professionals at the time of hospital discharge. The utility of this model for patient counseling and strategies to optimize postpartum care for high-risk individuals will require further evaluation.


Establishing a clinical informatics umbilical cord: lessons learned in launching infrastructure to support dyadic mother/infant primary care

Seuli Bose-Brill, Rachel D’Amico, Adam Bartley, Robert Ashmead, Paola Flores-Beamon, Shadia Jallaq, Kevin Li, Shengyi Mao, Shannon Gillespie, Naleef Fareed, Kartik K Venkatesh, Norah L Crossnohere, Jody Davis, Alicia C Bunger, Allison Lorenz


The manuscript describes the MOMI PODS transition and management clinical informatics platforms developed to facilitate MOMI PODS referrals, scheduling, evidence-based multidisciplinary care, and program evaluation.



Examining differences in retention on medication for opioid use disorder: An analysis of Ohio Medicaid data

Pengyue ZhangKrystel Tossone,  Robert AshmeadTina BickertEmelie BaileyNathan J. DooganAimee MackSchuyler SchmidtAndrea E. Bonny
Journal of Substance Abuse Treatment

The aim of this study was to examine patterns of retention in treatment on three different types of MOUD using administrative claims data from the Ohio Department of Medicaid, in consideration of behavioral health treatment (BHT) and other covariates.


Use of Medications for Treatment of Opioid Use Disorder Among US Medicaid Enrollees in 11 States, 2014-2018

Julie M. Donohue, Marian P. Jarlenski, Joo Yeon Kim, Lu Tang, Katherine Ahrens, Lindsay Allen, Anna Austin, Andrew J. Barnes, Marguerite Burns, Chung Chou H. Chang, Sarah Clark, Evan Cole, Dushka Crane, Peter Cunningham, David Idala, Stefanie Junker, Paul Lanier, Rachel Mauk, Mary Joan McDuffie, Shamis Mohamoud, Nathan Pauly, Logan Sheets, Jeffery Talbert, Kara Zivin, Adam J. Gordon, Susan Kennedy


In this exploratory serial cross-sectional study using data from 1 024 301 Medicaid enrollees in 11 states, the prevalence of medication treatment for OUD increased from 47.8% (138 918 of 290 638 enrollees with OUD) in 2014 to 57.1% (301 499 of 527 983) in 2018. There was substantial variation across and within states in any use and continuity (for 180 days) of medications for OUD by age, race/ethnicity, eligibility group, behavioral health comorbidity, and rural vs urban residence.


Healthcare Patterns of Pregnant Women and Children Affected by OUD in 9 State Medicaid Populations

Jarlenski, Marian PhD, MPH; Kim, Joo Yeon MS; Ahrens, Katherine A. PhD, MPH; Allen, Lindsay PhD, MA; Austin, Anna PhD; Barnes, Andrew J. PhD; Crane, Dushka PhD; Lanier, Paul PhD; Mauk, Rachel PhD; Mohamoud, Shamis MA; Pauly, Nathan PhD; Talbert, Jeffrey PhD; Zivin, Kara PhD, MS, MA; Donohue, Julie M. PhD
Journal of Addiction Medicine

State Medicaid programs are the largest single provider of healthcare for pregnant persons with opioid use disorder (OUD). Our objective was to provide comparable, multistate measures estimating the burden of OUD in pregnancy, medication for OUD (MOUD) in pregnancy, and related neonatal and child outcomes.



What should we teach about disability? National consensus on disability competencies for health care education

Susan M. Havercamp, Wesley R. Barnhart,  Ann C. Robinson, Cara N. Whalen Smith
Disability and Health

Health care providers are unprepared to meet the health needs of patients who have disabilities. Disability training is needed, yet there is little agreement about what should be taught.


Getting comfortable with disability: The short- and long-term effects of a clinical encounter

Jill M. Crane, Jesse G. Strickler, A. Todd Lash, Allison Macerollo, Jessica A. Prokup, Kelly A. Rich, Ann C. Robinson, Cara N. Whalen Smith, Susan M. Havercamp

Physicians report discomfort when interacting with patients with disabilities, which can negatively impact the quality of health care they provide.




Operationalizing and selecting outcome measures for the HEALing Communities Study

Svetla Slavova, Marc R. LaRochelle, Elisabeth D.Root, Daniel J.Feaster, Jennifer Villani, Charles E. Knott, Jeffery Talbert, Aimee Mack, Dushka Crane, Dana Bernson, Austin Booth, Sharon L. Walsh
Drug and Alcohol Dependence

The Helping to End Addiction Long-termSM (HEALing) Communities Study (HCS) is a multisite, parallel-group, cluster randomized wait-list controlled trial evaluating the impact of the Communities That HEAL intervention to reduce opioid overdose deaths and associated adverse outcomes. This paper presents the approach used to define and align administrative data across the four research sites to measure key study outcomes.



A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants

Dushka Crane, Michael Marcotte, Mary Applegate, Richard Massatti, Mark Hurst, Michelle Menegay, Rachel Mauk, Susan Williams
Journal of Substance Abuse Treatment

A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid.


Evidence for the Fidelity and Effectiveness of Living Independent From Tobacco for People with Disabilities and Their Caregivers

Havercamp SM, Barnhart WR, Ellsworth D, Coleman E, Lorenz A, Whalen Smith CN, Riddle IK
Tobacco Use Insights

People with disabilities (PWD) are more likely to use tobacco and less likely to access tobacco cessation programs compared with people without disabilities. Living Independent From Tobacco (LIFT), an evidence-based intervention designed for PWD, was piloted with dyads of PWD (n = 5) and their caregivers (n = 7). As an important source of practical and social support for PWD, caregivers also impact health-related attitudes, knowledge, and behaviors of PWD. Caregivers who smoke may unwittingly interfere with cessation efforts of the people they support. We found that LIFT could be offered to dyads of PWD and their caregivers with fidelity. The intervention was associated with increased use of coping strategies and self-efficacy to reduce smoking. Tobacco use decreased at post-test (–34.94%), with further reduction 6-months after the intervention (–50.60%). Implications for offering inclusive health promotion interventions to both PWD and their caregivers are discussed.


The Impact of Geographic Isolation on Mental Disability in the United States

Hudson CG, Doogan NJ
SSM - Population Health

Geographic isolation has long been hypothesized to have a role in the origins and development of mental disabilities. A considerable body of research has established such a correlation. However, study designs have limited researchers’ ability to establish a causal connection and rule out rival hypotheses.


Quitting behaviors among dual cigarette/e-cigarette users and cigarette smokers enrolled in the Tobacco User Adult Cohort (TUAC)

Sweet L, Brasky TM, Cooper S, Doogan NJ, Hinton A, Klein EG, Nagaraja H, Quisenberry A, Xi W, Wewers ME
Nicotine & Tobacco Research

We examined quitting behaviors among a cohort of dual users (cigarettes and electronic cigarettes [e-cigarettes]) and exclusive cigarette smokers for: (1) cigarette smoking reduction, (2) quit attempts, (3) abstinence from cigarettes, and (4) abstinence from all tobacco products.


Prepregnancy Insurance and Timely Prenatal Care for Medicaid Births: Before and After the Affordable Care Act in Ohio

Adams EK, Dunlop AL, Strahan AE, Joski P, Applegate M, Sierra E*
Journal of Women's Health

Persistent instability in insurance coverage before and after pregnancy among low-income mothers in the United States contributes to delayed prenatal care and poor infant outcomes. States that expand Medicaid under the Affordable Care Act (ACA) make public insurance free for many low-income women regardless of parental or pregnancy status. Our objective is to analyze the effects of expanding Medicaid in Ohio on enrollment of pregnant women and receipt of recommended prenatal care. A key objective in the state is to address infant mortality as Ohio ranks above the national average and racial disparities persist.


A Global Health Training Model for Teaching Pediatric Clinical Decision Making Skills to Rwandan Physical Therapists: A Case Report

Clark K, Whalen Smith CN, Kohls L, Musabyemariya I, Kayonga Ntagungira E, Mann M, Fisher SR
Physiotherapy Theory and Practice

This case report describes a model for improving pediatric clinical decision making skills among Rwandan physical therapists using best practices in clinical decision making, evidence-based practice where possible, and use of the International Classification of Functioning and Disability (ICF) model.


The role of travel distance and price promotions in tobacco product purchase quantity 

Doogan NJ, Cooper S, Quisenberry AJ
Health & Place

Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. 


Validation of a New Geographic Isolation Scale: A Tool for Rural Health Disparities Research

Doogan NJ, Roberts ME, Wewers ME, Tanenbaum ER, Mumford EA, Stillman FA
Social Science & Medicine

The purpose of this study was to develop and test a new continuous measure for rural health disparities research that characterizes geographic areas according to a perspective of access to resources.


Regional Rural-Urban Differences in E-Cigarette Use and Reasons for Use in the United States

Mumford E, Stillman FA, Tanenbaum E, Doogan NJ, Roberts ME, Wewers ME 
Journal of Rural Health

Urban‐rural disparity has increased in the last decade due to declining urban smoking and stagnant rural rates. Concomitantly, smoking‐related diseases in rural areas consistently exceed rates in urban areas.


Smoking prevalence and trends among a U.S. national sample of women of reproductive age in rural versus urban settings

Nighbor TD, Doogan NJ, Roberts ME, et al
The aim of the present study was to examine whether this rural-urban disparity impacts women of reproductive age (ages 15-44) including pregnant women. Data came from the ten most recent years of the U.S. National Survey on Drug Use and Health (2007-2016).


A Medicaid Quality Improvement Collaborative on Psychotropic Medication Prescribing for Children

Thackeray J, Crane D, Fontanella C, Sorter M, Baum R, Applegate M
Psychiatric Services

A Medicaid statewide quality improvement (QI) collaborative was developed to improve antipsychotic prescribing practices for children. With use of a multistrategy approach that incorporated data-driven feedback and evidence-based recommendations, improvements were seen in three measures: antipsychotics prescribed to children under age six, prescription of two or more concomitant antipsychotics for longer than two months, and prescription of four or more psychotropic medications. Challenges and complexities are reviewed, including use of ongoing QI to address factors influencing antipsychotic prescribing behaviors, engagement of providers in QI efforts, and financial sustainability of such efforts.


Local Income Inequality, Individual Socioeconomic Status, and Unmet Healthcare Needs in Ohio, USA

Tumin D, Menegay M, Shrider EA, Nau M, Tumin R*
Health Equity

Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set.


The 2018 Ohio Community Health Worker Statewide Assessment: Key Findings

Whalen Smith CN, Reed Robinson H, Carter N, Kirkland C
Ohio Department of Health

In order to gain a more accurate picture of the Community Health Worker (CHW) landscape in Ohio, this statewide CHW capacity assessment sought to identify how CHWs are currently being trained, certified, employed, reimbursed, and utilized in Ohio.



A Method for Accounting for Classification Error in a Stratified Cellphone Sample

Berzofsky ME, Scruggs CB, Speizer H, Peterson KC, Lu B, Sahr TR
Journal of Survey Statistics and Methodology

State-based telephone surveys are often designed to make estimates at substate levels, such as county or county group. Under a traditional random-digit-dial design, the telephone exchange of a landline number could be used to accurately identify the county for which the associated household resides. However, initially, no good analogous data methods existed for the cellphone frame. This required survey methodologists to draw random samples of cellphone numbers from the entire state, making it difficult to target areas within a state. To overcome this shortcoming, sample vendors have used a cellphone number’s rate center (where the number was activated) as a proxy estimate for the county where the cellphone owner resides. Our paper shows that county assignations that are based on rate center data may have classification error rates as high as 30%. These high classification error rates make it difficult to accurately devise a cellphone frame sample allocation using the rate center data. This paper proposes a new method—the Rate Center Plus method—which uses rate centers and an estimate of the classification probabilities to stratify and allocate the desired respondent sample to counties. The new method uses Bayes’ rule to distribute a desired county-level sample allocation across rate center counties. We demonstrate how the Rate Center Plus method was applied to the 2015 Ohio Medicaid Assessment Survey and the resulting efficacy of the method. Finally, we evaluate whether the new approach is more efficient than the traditional statewide sample method. In addition, we look at four approaches to estimating the necessary classification probabilities. We found that the Rate Center Plus method can be more cost efficient than the statewide sample method when the classification probabilities are reasonably estimated, reducing data collection costs as much as 12.8%.


Client-Centered Contraceptive Care Change Package

Ohio FQHC Infant Vitality Initiative

The Ohio Perinatal Quality Collaborative (OPQC) partnered with Cicatelli Associates Inc (CAI), the Ohio Association of Community Health Centers (OACHC) the Ohio Department of Medicaid (ODM) and the Ohio Colleges of Medicine Government Resource Center (GRC) to implement the Ohio FQHC Infant Vitality Initiative. The aim of this initiative was to improve infant vitality and maternal health by empowering women with information and services to optimize timing and spacing of their pregnancies. The project involved five FQHC networks and improved client-centered care by training teams on evidence-based clinical practices, long-acting reversible contraceptives (LARC) stocking and financing, workflow, and contraceptive counseling.


Transportation Challenges for Ohioans with Disabilities

Ohio Developmental Disabilities Council

The Ohio Developmental Disabilities Council (DD Council) commissioned the Ohio Colleges of Medicine Government Resource Center (GRC) to study the question of access to transportation for Ohioans with disabilities. From June 23 through October 17, 2016, GRC conducted an open, online survey of Ohioans with disabilities, as well as of transportation providers and professionals serving these populations. The survey investigated barriers to accessing and offering transportation, experiences using transportation, and recommendations for improving transportation availability, accessibility and usability. 



Unique and common elements of the role of peer support in the context of traditional mental health services

Crane D, Lepicki T, Knudsen K
Psychiatric Rehabilitation Journal

Objective: The goal of this report is to clarify the unique role of peer support providers (PSPs) and define peer support as a distinct occupation in the context of traditional mental health services. Method: A systematic methodology was used to compare roles of PSPs with those of similarly situated case managers (CMs). Key informants including 12 incumbent CMs and 11 incumbent PSPs participated in focus groups and responded to a set of prompts based on the Discovering a Curriculum (DACUM) methodology (Norton & Moser, 2014), an innovative approach to identifying and comparing duties and tasks associated with distinct occupations. Task analyses were validated through a survey of 71 CM and 29 PSP subject matter experts, including workers, supervisors, trainers, and consumers. Results: The results revealed a variety of duties and tasks specific to the PSP occupation, particularly within the domains of empowering consumers, promoting consumers’ educational growth, and supporting personal development. The results also reveal areas of overlapping responsibility between PSPs and CMs, including aspects of each role that promote consumers’ development, wellness and recovery, administrative tasks, and care coordination activities. Conclusions and Implications for Practice: These findings may address the role ambiguity that currently challenges efforts to establish peer support as a legitimate service in the field of behavioral health. In addition, the findings demonstrate how the roles of PSPs and CMs could be synergistic in complex organizational settings. 


Behavioral Health and Primary Care Integration in Ohio’s Psychiatry Residency Training

Reed E, Crane D, Svendsen D, et al
Academic Psychiatry

Integration of behavioral health and primary care is described as a gold standard for improving quality of care [1, 2]. Widespread consensus (e.g., World Psychiatric Association, June 2015), backed by a growing body of research, suggests that integration is an effective strategy for achieving the Institute for Healthcare Improvement’s triple aim of (1) improving symptomatology, functioning, and quality of life outcomes; (2) reducing the high cost of care; and (3) improving patient satisfaction with care [3, 4, 5]. Within psychiatry, integration of care has been identified as a core strategy to address the shortage of psychiatric care [6] and establish a new role for psychiatry in health care reform [2]. Integrated care offers opportunities for mental health practitioners to expand their role as leaders of interdisciplinary treatment models associated with patient-centered medical homes and health home models. Collaborative care offers an opportunity to reach a larger population of patients and play a vital role in improving outcomes in new value-based systems of care. Psychiatry has also been called upon to take a more active role in managing routine medical problems and health risks posed by psychiatric medications, thus avoiding the cost of duplicate appointments, increasing access to care, and decreasing delays in receiving care.


The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women

Shellhaas C, Conrey E, Crane D, Lorenz A,  et al
Maternal and Child Health Journal

Objectives: To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods: We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results: Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.


Evaluation of the MEDTAPP Healthcare Access Initiative

Scheck McAlearney A, Sieck C, Sova L, Barash B, Huerta T

This evaluation focused on three priority areas: recruitment, training, and retention of health professionals to serve Ohio’s Medicaid population. Information was supplemented by data the schools provided in August 2016. A survey was distributed to preceptors to better understand the preceptor’s discipline and the type of community-based site. Internal and external project reviews were conducted by examining past project proposals and final reports since SFY 2012 to better understand the types of activities that were unique to each institution.



BEACON Childhood Obesity Network 

American Academy Of Pediatrics, Ohio Chapter

In 2007, The American Academy of Pediatrics, and 14 other collaborating organizations, provided Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity that guide clinicians in very specific terms about how to screen for, assess, and manage excess weight that may occur in the early years of life. The recommendations are rooted in scientific research, including a review of all available literature, compiled to formulate an optimal approach for effectiveness.



Children's Access to Psychiatric Care in Ohio: Final Report

Steinman KJ, Kelleher KJ, Dembe A, Shoben A
Ohio Colleges of Medicine Government Resource Center

Our findings confirm that wait times for child psychiatry in Ohio are often excessive. As agencies try to address this problem, the data from our appointment availability assessment can serve as a useful baseline to assess the effectiveness of their efforts. 


Caring for Children with Disabilities in Ohio: The Impact on Families

Goudie A, Ranbom L, Jamieson B*, Havercamp SM
Ohio Developmental Disabilities Council

Research shows that families caring for children with disabilities experience higher levels of family stress, curtailed employment opportunities,
and diminished rates of general well being than comparative families. Specifically, these stressors have a negative impact on the family’s economic and emotional well being.



Assessment of Ohio’s Enhanced Primary Care Home Initiative

Hull SK, Ginther S*, Crane D, Kropp D
Ohio Colleges of Medicine Government Resource Center

The Patient-Centered Medical Home (PCMH) concept was pioneered by a group of primary care specialty societies (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association) and has been at the forefront of health system redesign efforts for a number of years. As advocacy for and evidence supporting this model has grown, it has been incorporated into numerous regional and local health system reform efforts and included in the Patient Protection and Affordable Care Act as a part of national health care reform.


Proceedings of the BEACON Quality of Care Measurement Conference

Ranbom L ,Crane D, Ginther S*, Lorenz A, Jamieson B*, Sahr TR
Ohio Colleges of Medicine Government Resource Center

This report entitled “Proceedings of the BEACON Quality of Care Measurement Conference” was conceived as a strategy for the BEACON (Best Evidence for Advancing Child Health in Ohio NOW ) Council to focus on prioritizing its future work. During its first year in existence, the BEACON Council engaged in a process of developing an organizational structure and funding strategy to implement its mission (Advancing Health Outcomes through Partnerships and Improvement Science), and established a strong public/private partnership to support projects targeted towards important health issues. The Council successfully established a collaborative partnership to create an infrastructure for quality improvement science amongst the leaders of Ohio’s children’s health improvement projects. 



Key Findings and Next Steps of the Ohio Payment Reform Summit

Hayes B, Ranbom L , Jamieson B*, Crane D, Lorenz A, Sahr TR
Ohio Health Care Coverage and Quality Council, Ohio Department of Insurance

This report entitled “Key Findings and Next Steps of the Ohio Payment Reform Summit” is the culmination of many months of planning and discussions initiated by the Ohio Health Care Coverage and Quality Council (HCCQC). In order to facilitate the process of health care reform
in Ohio, the HCCQC decided last summer to hold a Payment Reform Summit of key health care stakeholders. The Summit’s 139 participants included consumers, physicians, hospitals, other health care practitioners, employers, and public and private health plans staff. The statewide health care Payment Reform Summit was held on Saturday, December 4, 2010. The Summit attracted 139 participants who spent the day considering reform strategies to improve the quality and cost of health care for all Ohioans. This report summarizes the key outcomes of the Summit. 



Identifying Health Care Needs of Rural Ohio Citizens: An Evaluation of a Two-stage Methodology

Birdwell SW, Calesaric (Robinson) H
The Journal of Rural Health

The purpose of this study was to determine the health care needs of rural Ohio from the perspectives of health care providers and consumers using a two-stage methodology. In stage one, 12 focus groups were conducted in six rural areas: six groups of consumers and six groups of health care providers. A total of 53 consumers and 53 health care providers participated in the sessions. The participants identified 124 health care issues. In stage two, a questionnaire was developed to determine the importance of all issues identified in the focus group sessions. The questionnaire was mailed to all focus group participants and also to individuals invited to participate in the focus groups who were unable to attend. Individuals were asked to rate the importance of each health care issue in their community on an 11-point scale 0=not important, 10=extremely important. A total of 207 (56.9%) usable questionnaires were returned. Mean (+ S.D.) values were calculated for each health care issue, and the most important were 1) issues related to the financing and cost of health services and insurance, and (2) concerns associated with characteristics and behaviors of rural residents. The two-stage methodology provides a mechanism for identifying the concerns of providers and consumers and allows for these perspectives to be considered in the planning and development of strategies to address issues surrounding rural health cure.