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Context: Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear. Purpose: The purpose of this study was to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an acute or chronic ACSC as the reason for hospitalization. Methods: Nebraska hospital discharge data (1999-2001) and the 2003 Area Resource File were used in this analysis. A multilevel logistic regression analysis was used to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an ACSC as the reason for hospitalization, after controlling for individual characteristics and county-level contextual factors stratified by 3 age groups. The eligibility for logistic regression was limited to patients from 28 rural Nebraska counties designated as HPSAs in 2001. Patients with commercial payers were excluded from the study. Findings: Elderly patients residing in rural Nebraska HPSAs with at least one RHC were significantly less likely to have a hospitalization due to chronic ACSCs. Conclusions: The presence of RHC is a significant factor associated with fewer hospitalizations for chronic ACSCs among the rural elderly residing in HPSAs.

Background Emergency departments (EDs) have become entry points for treating behavioural health (BH) conditions, thereby rendering the evaluation of their utilisation necessary. Objectives This study estimated behavioural-related hospital-based ED visits and outcomes of leaving against medical advice as well as the incurred charges within the primarily rural State of Nebraska. Also, the study correlated behavioural workforce distribution and location of EDs with ED utilisation. Methods Nebraska State Emergency Department Database provided information on utilisation of services, charges, diagnoses and demographic. Health Professional Tracking Services survey provided the distribution of EDs and BH workforce by region. To examine the effect of patient characteristics on discharge against medical advice, multivariable logistic regression modelling was used. Findings US$96.4 million were ED charges for 52035 visits for BH disorders over 3 years. Of these, 35% and 50% were between 25 and 44-years old and privately insured, respectively. The uninsured (OR:1.53, p=0.0047) and 45-64 years old (OR:2.31, p<0.001) had higher odds of leaving against medical advice. The findings from this study identified ED outcomes among high-risk cohort. Conclusions There were high ED rates among the limited number EDs facilities in rural Nebraska. Rural regions of Nebraska faced workforce shortages and had high numbers of ED visits at relatively few accessible EDs. Clinical implications Customised rural-centric public health programmes, which are based in clinical settings, can encourage patients to adhere to ED-treatment. Also, increasing the availability of BH workforce (either via telehealth or part-time presence) in rural areas can alleviate the problem and reduce ED revisits. [ABSTRACT FROM AUTHOR]

Objectives: Public health accreditation is intended to improve the performance of public health departments, and quality improvement (QI) is an important component of the Public Health Accreditation Board process. The objective of this study was to evaluate the QI maturity and accreditation readiness of local health departments (LHDs) in Nebraska during a 6-year period that included several statewide initiatives to progress readiness, including funding and technical assistance. Methods: We used a mixed-methods approach that consisted of both online surveys and key informant interviews to assess QI maturity and accreditation readiness. Nineteen of Nebraska's 21 LHDs completed the survey in 2011 and 2013, 20 of 20 LHDs completed the survey in 2015, and 19 of 20 LHDs completed the survey in 2016. We facilitated a large group discussion with staff members from 16 LHDs in 2011, and we conducted key informant interviews with staff members from 4 LHDs in 2015. Results: Both QI maturity and accreditation readiness improved from 2011 to 2016. In 2011, of 19 LHDs, only 6 LHD directors agreed that their LHD had a culture that focused on QI, but this number increased every year up to 12 in 2016. The number of LHDs that had a high capacity to engage in QI efforts improved from 3 in 2011 to 8 in 2016. The number of LHDs with a QI plan increased from 3 in 2011 to 10 in 2016. The number of LHDs that were confident in their ability to obtain Public Health Accreditation Board accreditation improved from 6 in 2011 to 13 in 2016. Although their QI maturity generally increased over time, LHDs interviewed in 2015 still faced challenges adopting a formal QI system. External financial and technical support helped LHDs build their QI maturity and accreditation readiness. Conclusion: Funding and technical assistance can improve LHDs' QI maturity and accreditation readiness. Improvement takes time and sustained efforts by LHDs, and support from external partners (eg, state health departments) helps build LHDs' QI maturity and accreditation readiness. [ABSTRACT FROM AUTHOR]

Not all women 50-74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients' breast cancer screening rate. Using medical record data of 8,347 women patients aged 50-74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients' mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This study examines multilevel factors related to colorectal cancer (CRC) screening in a rural Accountable Care Organization (ACO) setting. Methods: The study used electronic medical record data from 8 rural ACO clinics in Nebraska. The final sample included 15,866 average‐risk patients aged 50‐75 years who visited participating clinics at least once from June 2014 to May 2015. Logistic regression was conducted to examine simultaneous effects of patient, provider, and county characteristics on CRC screening after accounting for provider‐county‐level correlation using a generalized estimating equations method. Findings: The results indicated that patients aged 65 years and older, non‐Hispanic white, whose preferred language was English, who had insurance, who had a wellness visit in the past year, and who had chronic conditions were more likely to be up‐to‐date on CRC screening. Patients were also more likely to be up‐to‐date when their primary care provider was a female medical doctor who was aware of clinic CRC screening protocols or who manually checked patient CRC screening status during the patient visit. Patients in a county with no gastroenterologist, a high poverty rate, and low insurance coverage were less likely to be up‐to‐date on CRC screening. Conclusions:  A variety of patient, provider, and county characteristics were associated with CRC screening. Effective strategies to promote CRC screening should address multilevel factors, including: targeting patients with identified individual barriers, modifying physician and clinical practices, and focusing on communities with low socioeconomic status or low levels of medical resources. [ABSTRACT FROM AUTHOR]

Purpose: There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. Methods: A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. Findings: Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. Conclusion: The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues. [ABSTRACT FROM AUTHOR]

Objectives. We examined the relationship between quality improvement (QI) maturity and accreditation attributes of US local health departments (LHDs), specifically those in Nebraska. Methods. Using 2011 Nebraska LHD QI survey data, we conducted Spearman correlation analyses between QI maturity domains and accreditation attributes. Using the 2010 National Association of County and City Health Officials' National Profile of LHDs, we conducted logistic regression analyses to examine the relationships between specific QI strategies and attitude toward seeking accreditation. Results. Leaders' commitment to and length of time engaged in QI were positively associated with LHDs' general attitude toward seeking accreditation. Use of QI strategies and integration of QI policies and practices were positively associated with LHDs' confidence in their capacity to obtain accreditation. LHDs that had used at least 1 QI framework and at least 1 QI technique in the past year were more likely to agree that they would seek accreditation within 2 years of the national accreditation program. Conclusions. Experience with and expertise in QI implementation play an important role in LHDs' decision to seek accreditation, and their accreditation-seeking efforts may benefit from prior implementation of systematic QI strategies. [ABSTRACT FROM AUTHOR]

Context: Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear. Purpose: The purpose of this study was to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an acute or chronic ACSC as the reason for hospitalization. Methods: Nebraska hospital discharge data (1999-2001) and the 2003 Area Resource File were used in this analysis. A multilevel logistic regression analysis was used to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an ACSC as the reason for hospitalization, after controlling for individual characteristics and county-level contextual factors stratified by 3 age groups. The eligibility for logistic regression was limited to patients from 28 rural Nebraska counties designated as HPSAs in 2001. Patients with commercial payers were excluded from the study. Findings: Elderly patients residing in rural Nebraska HPSAs with at least one RHC were significantly less likely to have a hospitalization due to chronic ACSCs. Conclusions: The presence of RHC is a significant factor associated with fewer hospitalizations for chronic ACSCs among the rural elderly residing in HPSAs. [ABSTRACT FROM AUTHOR]

Objective: To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets., Design: A concurrent mixed-methods design using electronic health records, provider survey, and provider interview., Setting: Eight primary care accountable care organization clinics in Nebraska., Measures: Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system)., Analysis: Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding)., Results: At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors., Conclusions: This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.

Introduction: Effective collaboration between public health and the health care system is essential for connecting medical and community health-related resources and improving population health. We investigated the linkages between local health departments and primary care clinics in Nebraska., Methods: We conducted a mixed-method study by using semistructured in-person and telephone interviews and surveys in 2017 and 2018 with directors of 19 Nebraska local health departments. Interviews and surveys assessed activities and programs that health departments implemented or planned with clinics in their jurisdictions. Barriers, benefits, and opportunities for building the linkages were identified., Results: Strong linkages existed between local health departments and primary care clinics. Linkages focused on the control and prevention of chronic diseases and on traditional public health programs, including screening for cancer and other chronic diseases, vaccinations, worksite wellness programs, home visits, clinic and medication assistance referrals, health message development, electronic health records data analyses, staff education, and improvements in policies and procedures. The most frequently reported barrier was funding, and the most frequently reported benefit was patient behavior change. The opportunity most frequently reported was chronic disease health coaching., Conclusion: Extensive linkages exist between Nebraska local health departments and the health care systems in their areas. Additional funding, effective workforce management, community needs assessments, and program evaluation can support joint initiatives to address community health priorities.

Objective: To compare local health department (LHD) accreditation readiness (AR) and quality improvement (QI) maturity in 3 states, between LHDs with varying levels of rurality, and across an LHD staffing-level continuum., Design: This was a cross-sectional comparative study that included an online survey administered to LHD directors in Colorado, Kansas, and Nebraska. The survey included 10 questions assessed on a 5-point Likert scale covering 3 QI domains and 13 questions covering 5 AR domains. The median score for both QI maturity and AR was calculated by each state, by the number of full-time equivalent staff employed at the LHD, and by a measure of rurality and population density., Setting and Participants: A total of 156 LHDs from the states of Colorado, Kansas, and Nebraska., Main Outcome Measure(s): QI maturity and AR scores., Results: A majority (59%) of the surveyed LHDs plan to apply or have already applied for Public Health Accreditation Board (PHAB) accreditation. The overall QI maturity and AR scores were highest in Nebraska, as was the intent to seek PHAB accreditation and current use of PHAB standards. Across levels of rurality and staffing, LHD QI maturity scores were similar; however, AR scores improved as LHD staffing levels increased and rurality decreased., Conclusions: Small LHDs and rural LHDs have QI maturity levels that are comparable to larger, less rural LHDs, but their AR is much lower. As accreditation has been found to have positive benefits, it is important that all LHDs have the capacity and resources to meet the performance standards required of accredited LHDs. Small, rural LHDs may need additional resources and support in order to improve their ability to be accredited and/or certain accreditation requirements may need modification to make accreditation more accessible to small LHDs.

Objectives: Public health accreditation is intended to improve the performance of public health departments, and quality improvement (QI) is an important component of the Public Health Accreditation Board process. The objective of this study was to evaluate the QI maturity and accreditation readiness of local health departments (LHDs) in Nebraska during a 6-year period that included several statewide initiatives to progress readiness, including funding and technical assistance., Methods: We used a mixed-methods approach that consisted of both online surveys and key informant interviews to assess QI maturity and accreditation readiness. Nineteen of Nebraska's 21 LHDs completed the survey in 2011 and 2013, 20 of 20 LHDs completed the survey in 2015, and 19 of 20 LHDs completed the survey in 2016. We facilitated a large group discussion with staff members from 16 LHDs in 2011, and we conducted key informant interviews with staff members from 4 LHDs in 2015., Results: Both QI maturity and accreditation readiness improved from 2011 to 2016. In 2011, of 19 LHDs, only 6 LHD directors agreed that their LHD had a culture that focused on QI, but this number increased every year up to 12 in 2016. The number of LHDs that had a high capacity to engage in QI efforts improved from 3 in 2011 to 8 in 2016. The number of LHDs with a QI plan increased from 3 in 2011 to 10 in 2016. The number of LHDs that were confident in their ability to obtain Public Health Accreditation Board accreditation improved from 6 in 2011 to 13 in 2016. Although their QI maturity generally increased over time, LHDs interviewed in 2015 still faced challenges adopting a formal QI system. External financial and technical support helped LHDs build their QI maturity and accreditation readiness., Conclusion: Funding and technical assistance can improve LHDs' QI maturity and accreditation readiness. Improvement takes time and sustained efforts by LHDs, and support from external partners (eg, state health departments) helps build LHDs' QI maturity and accreditation readiness.

Not all women 50-74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients' breast cancer screening rate. Using medical record data of 8,347 women patients aged 50-74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients' mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.

Objective: To demonstrate an approach to measuring the cost and value of quality improvement (QI) implementation in local health departments (LHDs)., Design: We conducted cost estimation for 4 LHD QI projects and return-on-investment (ROI) analysis for 2 selected LHD QI projects., Setting and Participants: Four Nebraska LHDs varying in rurality and jurisdiction size., Main Outcome Measures: Total costs, unit costs, incremental cost-effectiveness ratios, and ROI., Results: The 4 QI projects vary significantly in their cost estimates. Estimated ROI ratios for 2 QI projects predicted significant savings in health care utilization for respective program participants. A QI project focused on improving breastfeeding rates in WIC (women, infants, and children) clients had a predicted ROI ratio of 3230% and a QI project for improving participation in a Chronic Disease Self-Management Program would need only 34 new participants to have a positive ROI., Conclusions: We demonstrated how data can be collected and analyzed for cost estimation and ROI analysis to quantify the economic value of QI for LHDs. Our ROI analysis shows that QI initiatives have great potential to enhance the value of LHDs' public health services. A better understanding of the costs and value of QI will enable LHDs to appropriately allocate and utilize their limited resources for suitable QI initiatives.

Background/aims: In 1996, Nebraska became the first state in the United States to establish a Parkinson's disease (PD) Registry. The objectives of this study were to determine the most common comorbid conditions among PD patients receiving inpatient and outpatient services in Nebraska between 2004 and 2012, and to examine whether PD patients had increased risks of these conditions., Methods: Statewide linkage was performed between Nebraska PD Registry data and hospital discharge database. The cohort comprised of 3,852 PD inpatients and 19,260 non-PD inpatients, and 5,217 PD outpatients and 26,085 non-PD outpatients. Referent subjects were matched to PD patients by age at initial hospital admissions or visits, gender, and county of residence using systematic random-sampling method., Results: Compared to non-PD inpatients, PD inpatients were at higher risks for dementia (relative risk [RR] 2.29; 95% CI 2.14-2.45), mood disorders (RR 1.57; 95% CI 1.44-1.70), gastrointestinal disorders (RR 1.15; 95% CI 1.06-1.25), and urinary tract infections (RR 1.33; 95% CI 1.22-1.45), while PD outpatients had higher risks for spondylosis (RR 1.23; 95% CI 1.09-1.38), genitourinary disorders (RR 1.48; 95% CI 1.29-1.69), gastrointestinal disorders (RR 1.59; 95% CI 1.38-1.84), and dementia (RR 2.83; 95% CI 2.38-3.37) than non-PD outpatients., Conclusions: The findings highlight PD as a multisystem neurodegenerative disorder, and this information is crucial for creating strategies to better prevent and manage PD complications., (© 2017 S. Karger AG, Basel.)

Objectives: We examined the relationship between quality improvement (QI) maturity and accreditation attributes of US local health departments (LHDs), specifically those in Nebraska., Methods: Using 2011 Nebraska LHD QI survey data, we conducted Spearman correlation analyses between QI maturity domains and accreditation attributes. Using the 2010 National Association of County and City Health Officials' National Profile of LHDs, we conducted logistic regression analyses to examine the relationships between specific QI strategies and attitude toward seeking accreditation., Results: Leaders' commitment to and length of time engaged in QI were positively associated with LHDs' general attitude toward seeking accreditation. Use of QI strategies and integration of QI policies and practices were positively associated with LHDs' confidence in their capacity to obtain accreditation. LHDs that had used at least 1 QI framework and at least 1 QI technique in the past year were more likely to agree that they would seek accreditation within 2 years of the national accreditation program., Conclusions: Experience with and expertise in QI implementation play an important role in LHDs' decision to seek accreditation, and their accreditation-seeking efforts may benefit from prior implementation of systematic QI strategies.

Introduction: Reducing childhood obesity remains a public health priority given its high prevalence and its association with increased risk of adult obesity and chronic diseases. The objective of this study was to examine the joint influence of multiple risk factors on adolescent overweight status., Methods: We conducted a random-digit-dialed telephone survey of adolescents aged 12 to 19 years in fall 2008 in a Midwestern city in Nebraska. On the basis of survey data for 791 youths aged 12 to 18 years, we conducted latent class analysis to group youths by the joint occurrence of dietary behavior, physical activity, parenting practices, and physician advice. We then examined the association between the groups and overweight status by using logistic regression, controlling for age, sex, race/ethnicity, and parent and family information., Results: Youths were clustered into 3 groups. Group I (52%) were youths with healthy dietary behavior and physical activity, less permissive parenting practices, and physician advice; Group II (30%) were youths with moderately healthy dietary behavior and physical activity, less permissive parenting practices, and no physician advice; and Group III (18%) were youths with unhealthy dietary behavior and physical activity, permissive parenting practices, and physician advice. Youths in Groups I and II were less likely to be overweight than youths in Group III., Conclusions: Youths with healthier behavior and less permissive parenting practices were less likely to be overweight. Study findings highlight the need to address obesity risk factors among youths with unhealthy dietary behavior, inadequate exercise, permissive parenting practices, and some physician advice. Tailored interventions should be used to target youths with different obesity risk factors.

Objective: This study examined the relationship between county variation in macro contextual variables and the performance of public health practice in regional local health departments (LHDs) in Nebraska. DESIGN AND MAIN OUTCOMES MEASURES: County-level data from the US Census Bureau, the Nebraska Department of Health and Human Services, and the University of Nebraska Medical Center's Health Professions Tracking Services were used to create macro context variables (eg, demographic, geographic, social, economic, population health status). The public health performance data were collected through a mail survey of the directors of regional LHDs in Nebraska in 2008. Public health performance measures were created to indicate LHD's general performance as well as core function specific performance (ie, assessment, assurance, policy development). The coefficients of variation were estimated and used to categorize each regional LHD into either a larger county variation group or a smaller county variation group for each domain of macro context variables. Statistical comparisons of public health performance measures were then made between these 2 groups for each domain., Results: The results suggest that the county variation in macro contextual variables within a regional public health district, in general, is negatively associated with the performance of public health practice in regional LHDs. The regional LHD's performance in specific public health core function (eg, assurance) is negatively associated with the county variation in specific types of macro context factors (eg, geographic factors such as land size and population density)., Conclusions: Regional LHDs may design and implement their public health programs on the basis of the type and degree of heterogeneity among the member counties within their jurisdiction. The formation of regional LHDs, if possible, should follow geographic boundaries that minimize the heterogeneity of county composition in terms of macro contextual factors.

Objective: The purpose of this study is to examine the effectiveness and challenges of regional public health partnerships by exploring the experiences of 2 multicounty LHDs in Nebraska., Settings: The selection of the 2 local health department (LHD) sites was on the basis of the history of prior collaborative partnership in the LHD jurisdiction. Both regional LHD jurisdictions cover a service area of 9 counties., Design: A mixed method research design was used for this study. We first conducted an online survey to create an inventory of partnerships for each LHD site. Then, we collected quantitative data to measure the effectiveness of partnerships through a survey of community partners in both LHD sites. We also collected qualitative information through telephone interviews with community partners and LHD staff to examine the challenges for building an effective regional partnership., Results: Regional public health partnerships are most effective in efficiency, but less effective in the areas of management and resource sufficiency. More effort is still needed to maximize the collaborative potential for the majority of partnerships in both regions. In particular, geographic distance and work demand were identified as the 2 major challenges by community partners. The community health planning partnership in the LHD site with prior history of collaboration was more effective than its counterpart without such history., Conclusions: Policy makers should consider developing policies to assist multicounty LHDs with improving their management of regional partnerships and with providing sufficient resources to support their regional partnerships. If possible, the formation of regional community health planning partnership should follow the geographic boundaries where prior collaboration already existed.

Objective: This study examined the mechanism of resource allocation among member counties and the funding challenges of regional health departments (RHDs) in Nebraska. DESIGN AND STUDY SETTING: In 2009, we conducted a qualitative case study of 2 Nebraska RHDs to gain insight into their experiences of making resource allocation decisions and confronting funding challenges. The 2 RHD sites were selected for this case study on the basis of their heterogeneity in terms of population distribution in member counties. Sixteen semistructured in-person interviews were conducted with RHD directors, staff, and board of health members. Interview data were coded and analyzed using NVivo qualitative analysis software (QSR International [Americas] Inc., Cambridge, MA)., Results: Our findings suggested that the directors of RHDs play an integral role in making resource allocation decisions on the basis of community needs, not on a formula or on individual county population size. Interviewees also reported that the size of the vulnerable population served by the RHD had a significant impact on the level of resources for RHD's programs. The RHD's decisions about resource allocation were also dependent on the amount and type of resources received from the state. Interviewees identified inadequacy and instability of funding as the 2 main funding challenges for their RHD. These challenges negatively impacted workforce capacity and the long-term sustainability of some programs., Conclusions: Regional health departments may not benefit from better leveraging resources and building a stronger structural capacity unless the issues of funding inadequacy and instability are addressed. Strategies that can be used by RHDs to address these funding challenges include seeking grants to support programs, leveraging existing resources, and building community partnerships to share resources. Future research is needed to identify RHDs' optimal workforce capacity, required funding level, and potential funding mechanisms.

Objective: This article describes the evaluation and findings of a community-based prenatal care program, Omaha Healthy Start (OHS), designed to reduce local racial disparities in birth outcomes., Design: This evaluative study used a comparative descriptive design, and Targeting Outcomes of Programs was the conceptual framework for evaluation., Sample: The evaluation followed 3 groups for 2 years: OHS birth mothers (N=79; N=157); non-OHS participant birth mothers (N=746; N=774); and Douglas County birth mothers (N=7,962; N=7,987)., Measurement: OHS provided case management, home visits, screening, referral, transportation, and health education to participants. Program outcome measures included low birth weight, infant mortality, adequacy of care, trimester of care, and costs of care., Results: OHS birth outcomes improved during year 2, and there was a 31% cost saving in the average hospital expenditure compared with the nonparticipant groups. Preliminary evaluative analysis indicates that prenatal case management and community outreach can improve birth outcomes for minority women, while producing cost savings., Conclusions: Further prospective study is needed to document trends over a longer period of time regarding the relationship between community-based case management programs for minority populations, birth outcomes, and costs of care.