Rural Health Research Group

UCF College of Health Professions and Sciences


Building on previous research of Rural Health Clinics and Health Centers throughout the U.S., the Rural Health Research Group (RHRG) was formed in 2011.

The Rural Health Research Group seeks to improve healthcare delivery to rural populations, and to contribute to achieving health equity of specific minority groups within rural populations.  The Group’s research involves analyzing large secondary data sets, as well as conducting surveys, interviews and focus groups with healthcare providers and residents of rural communities.

The Rural Health Research Group is a multi-college research group with faculty, graduate and undergraduate research assistants from the following colleges:

Lead team members:


Judith Ortiz, Ph.D.
Director of Rural Health Research Group
Research areas: Healthcare delivery systems; rural health; and primary care.


Richard A. Hofler, Ph.D.
Richard Hofler is an econometrician and health economist with extensive data analysis experience. He has published articles dealing with various issues in econometrics and health care and numerous articles using many different advanced statistical methods. Hofler is also co-PI on a current AREA grant funded by NIH which involves (1)measuring the disparities in diabetes-related hospitalization rates between rural Latino older adult patients and rural non-Latino White older adult patients, and (2) identifying factors related to reduced disparities in diabetes-related hospitalization rates of rural Latino older adult patients. Finally, hofler has successfully managed and completed several large Federally-funded grants (NIH, NSF, AHRQ, and DOJ) as PI or Co-PI.


Angeline Bushy, Ph.D., R.N
Research areas:  Rural Health and Community Nursing 

The Rural Health Research Group is funded by the National Institutes of Health (NIH), and (previously) the Health Resources and Services Administration (HRSA.)

  • NIH-funded: “Reducing Diabetes-related Hospitalizations of Rural Latinos”
  • NIH-funded: “Rural Health Clinics in Accountable Care Organizations”
  • HRSA-funded: “Rural Health Clinics: Measuring Efficiency and Effectiveness”

During the last few years, our research team has assembled a unique dataset and conducted analyses of a panel of approximately 2,700 Rural Health Clinics (RHCs) located throughout the U.S. for the 8-year period of 2008 – 2015.  The dataset contains approximately 500 variables, including RHC characteristics, demographic data for the 904 rural counties where RHCs are located, and healthcare and health outcome data for approximately 1,300,000 Medicare beneficiaries served by RHCs.  We are in the process of adding data for more than 1,500,000 patients served by Community Health Centers (CHCs), including those receiving Medicaid.

For more information please contact us at:

What We Do

The work of the Rural Health Research Group contributes to the research base for understanding rural populations.  Our research contributes to informing policy to improve the welfare of rural populations.

Areas of Expertise

  • Health disparities: rural vs. urban; ethnic/racial minorities
  • Primary healthcare evaluation: patient care and outcomes; cost of care
  • Transition costs of primary care organizations (e.g. to Patient-Centered Medical Homes)
  • Intervention effects analysis of clinical, training, and policy interventions
  • Cost analysis of clinical and non-clinical interventions
  • Efficiency analysis of healthcare organizations

Research Activities

  • Analytical modeling
  • Statistical analyses of data from multiple federal sources
  • Interviews
  • Focus Groups
  • Surveys

Inform Policy

Our research informs policy through our publications, reports to federal agencies, and presentations at national and state conferences of rural health professional associations.

Major Projects and Principal Findings

This is a longitudinal study of data from FL, TX, and CA to:  1) compare health disparities and patient outcomes of rural Latino older adult patients diagnosed with diabetes to their non-Latino White counterparts, and 2) ascertain the impact of Accountable Care Organization (ACO) participation by rural primary care providers (along with other factors) on rural Latino older adult patients.

Major findings: This project is underway.

This study analyzed the impact of Accountable Care Organizations (ACOs) on health disparities and patient outcomes of rural populations.  ACOs are one of the new models for healthcare delivery.  ACOs that are sponsored by Medicare are provider-run groups of physicians, hospitals, and/or other health care organizations that are intended to provide coordinated high quality care to the Medicare patients they serve.  Using a sample of 828 Rural Health Clinics (RHCs) located in nine states, we analyzed the impact of one type of Medicare ACO (the Medicare Shared Savings Program or MSSP ACO) on health disparities, cost efficiency, and preventive care effectiveness.  We compared the performance of: 1) RHCs before and after they joined an ACO, and 2) ACO-RHCs to that of similar non-ACO RHCs (those that chose not to join an ACO.)

Among the major findings of this project were that:

  • Few Rural Health Clinics (RHCs) participated in Medicare Shared Savings Program ACOs (MSSP ACOs) in the early years of the Program’s history (2012 and 2013.)
  • Independent and larger RHCs participated in ACOs in greater numbers than did provider-based (hospital- or nursing home-affiliated) and smaller RHCs.
  • MSSP ACO participation positively influenced the average pneumococcal vaccination rates for African American Medicare beneficiaries of RHCs.
  • RHCs that participated in MSSP ACOs had better cost efficiency then did the non-ACO RHCs.
  • During the early Program years, MSSP ACOs appeared to have no influence on hospitalizations of the RHC beneficiaries they served as related to COPD/asthma, diabetes, heart failure, or pneumonia.

The goal of the study was to determine:  1) the factors that influence the variation in Rural Health Clinic (RHC) performance (efficiency and effectiveness), and 2) the relationship of the two aspects of performance.  The research team conducted a survey, a focus group, and analyses of secondary data for 3,565 Rural Health Clinics located throughout the U.S.

Among the major findings of this project were that:

Survey Findings:  Multivariate Analysis

Based on the survey findings, the following factors were positively and significantly related to efficiency:  cost efficiency (for all RHCs), and Midwest location (for provider-based RHCs).  The following factors were negatively associated with efficiency:  non-profit status and number of years of Medicare certification (for independent RHCs).  The following factor was positively and significantly associated with effectiveness:  provider-based RHCs.  Finally, technology use was negatively associated with effectiveness (for all RHCs).

Focus Group Findings

The following table describes the focus group topics and most common responses.

TopicMost Common Response or Theme
Factors Contributing to Efficient RHCsStaff: Sufficient, competent, stable
Additional Resources Needed for EfficiencyContinuing education for staff and providers
Barriers to Achieving EfficiencyFinances: Insufficient
Factors Contributing to Effective RHCsProvision of quality services
Tools Used to Monitor EffectivenessProvider activity monitoring tools
Resources Needed to Monitor EffectivenessAdditional software
Findings of Multivariate Analysis of Secondary Data

We used two indicators of efficiency in the analysis of secondary data:  technical efficiency (a productivity measure), and cost per visit.  We used two groups of indicators of effectiveness:  the provision of preventive diabetic care services, and the rate of ambulatory care sensitive conditions (ACSC) for diabetes, COPD, and CHF.

Larger RHCs of both classifications – independent and provider-based – were found to be more efficient as measured by productivity and cost per visit.

Midwestern provider-based RHCs (those integrated with Medicare-certified hospitals, nursing homes, or home health agencies and located in the Midwest) are more cost efficient.

The hypothesis that effectiveness of RHCs is positively influenced by efficiency was not supported.


A sampling of publications resulting from the above projects follows:

Lin, Y., Du, Y., Gomez, C., & Ortiz, J. (2017).  Does Patient-Centered Medical Home recognition relate to Accountable Care Organization participation?  Population Health Management.  [DOI: 10.1089/pop.2017.0096]

Hofler, R. & Ortiz, J.  (2016). Costs of ACO participation for primary care providers:  First year results.  BMC: Health Services Research, 16:315. [DOI: 10.1186/s12913-016-1556-6]

Ortiz, J., Hofler, R.A., Lin, Y. L., & Berzon, R.  (2015). Participation of rural healthcare providers in Accountable Care Organizations:  Early indications.  The Health Care Manager, 34(3):255-264. [DOI:10.1097/HCM.0000000000000069]

Wan, T. T. H., Masri, M.D., & Ortiz, J. (2014).  Willingness to participate in ACOs: Healthcare managers’ perspective. The Health Care Manager, 33(1): 64-74[DOI:10.1097/01.HCM.0000440625.92879.e8]

Ortiz, J., Bushy, A., Zhou, Y., & Zhang, H.  (2013).  Accountable Care Organizations: Benefits and barriers as perceived by Rural Health Clinic management.  Rural and Remote Health 13: 2417. [PMC:3761377]

Ortiz, J., Meemon, N., Zhou, Y., & Wan, T.T.H.  (2012).  Trends in rural health clinics and needs during U.S. health reform.  Primary Health Care Research and Development, 14(4): 360-366.  [DOI:10.1017/S1463423612000503]

Ortiz, J. & Bushy, A.  (2011).  A focus group study of rural health clinic performance.  Family & Community Health 34(2), 111-118.

Ortiz, J., Wan, T.T.H., Meemon, N., Paek, S.C., & Agiro, A.  (2010).  Contextual correlates of Rural Health Clinics’ efficiency:  Analysis of nurse practitioners’ contributions.  Nursing Economics 28(4), 237-244.

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