Description 

My doctoral research explores the ways that urbanist ideology shows up in rural hospital strategic decision-making. I am examining the literature about rural hospital mergers with a larger health network to understand whether affiliation with a system impacts the types of knowledge that are used in considering health services delivery changes.

Health services provision in rural areas is complicated by geographic, economic, and social factors. The post-Affordable Care Act healthcare landscape has seen a strong trend towards health system consolidation. Despite a decade of increasing incidence, relatively little research has been reported regarding the reasons for and outcomes of rural hospital mergers. The evidence that does exist reflects a mix of positive and negative impacts. What the literature does and does not say about the effects of rural hospital affiliations on the acquired hospitals and their communities reflects dominant ideas about what knowledge is worth knowing and sharing. 

This work expands the nascent field of structural urbanism by uncovering epistemic blind spots in the literature and in health systems management and practice. Structural urbanism in healthcare is currently understood as “emerging from a focus on individuals rather than infrastructure when designing health care and public health interventions” (Probst et al., 2019). This study seeks to deepen our understanding of this phenomenon by uncovering the taken-for-granted assumptions about and orientation towards rural experience and knowledge that underpin and uphold the dominant urban view of how health care should be.

Funding/Support

My doctoral research is funded in part through a Social Sciences and Humanities Research Council (SSHRC) Joseph-Armand Bombardier Canada Graduate Scholarship. I am supported by my supervisors, Dr. Agnes Grudniewicz and Dr. Suhaib Riaz.

Outputs

• Preprint: 

  • Coates, A., Probst, J., Sarwal, K., Riaz, S., Grudniewicz, A. The Impact of Rural Hospital Closures and Mergers on Health System Ecologies: A Scoping Review. Preprint: 10.1101/2025.01.31.25321470v1. (Under review after 1st revision).

• Manuscripts in development: 

  • Coates, A., Probst, J., Grudniewicz, A., Riaz, S. Mobilizing Support for Rural Hospital Strategic Decisions Following a Merger: Frame Alignment Through Information Exchange. (Manuscript in development).

  • Coates, A., Probst, J., Grudniewicz, A., Riaz, S. Considering Community Needs in Hospital Strategic Decision-making. (Manuscript in development).

• Posters and Presentations:

  • Coates, A., Sarwal, K., Probst, J., Riaz, S., Grudniewicz, A. (2024). Effects of Rural Hospital Mergers: What We Do and Do Not Know [Poster]. New York State Association for Rural Health - Rural Health Symposium, Binghamton, NY. September 2024. 

• Media:

  • “Health care was built for cities. This researcher seeks a better fit for rural areas: Interview with Alison Coates.” Interview with Sommerstein, D. (2023, October 4). NCPR Story Of The Day. North Country Public Radio.

Description

Mental health and wellbeing has been identified as a top issue by rural stakeholders nationally, as well as by state stakeholders informing the new New York State Prevention Agenda. The New York State Association for Rural Health (NYSARH) aims to support collective action towards improving rural mental health outcomes in two ways: 1) by synthesizing data related to mental health and wellbeing from disparate sources across rural New York State to produce a Statewide Aggregate Rural Health Needs Assessment informing localized efforts; and 2) by establishing the Rural Health Impact Collaborative as a replicable model, based on the Collective Impact Framework, that supports and sustains rural community sector action towards improving local mental health outcomes.

Successful completion of the SARHNA will provide a clear picture of the state of mental health and wellbeing in rural New York State. This knowledge will permit us to strategically plan the Collaborative’s work, as well as NYSARH’s advocacy and education work. Successful establishment of the Collaborative will result in the alignment of multiple regions to impact 1-3 measures over time, and will engage our membership to participate in new ways of working together.  

This project lays the foundation and establishes a baseline for future impact related to rural community mental health and wellbeing. Successful completion of the SARHNA will suggest existing data and measures which can be followed over time to monitor our impact on population-level measures at the sub-county and county level.

Funding/Support

This project has been funded by the New York Health Foundation Special Projects Fund. 

Description

The rural-urban dimension of health equity has always been the primary concern for the New York State Association for Rural Health (NYSARH). Our core work is to advocate for the interests of rural New York health communities and to provide education to better support rural health needs. As we evaluate our health equity work going forward, we acknowledge that we serve the majority of our stakeholders well, but that there are hidden intersectional dimensions of inequity that affect rural New Yorkers. 

Phase 1 (complete): Our organization has begun to look at the diversity characteristics of our stakeholders, our members, and our board to better understand our gaps. Are there sub-populations within New York State that merit better representation at NYSARH? Our most pressing question to broaden our health equity work to be more inclusive is, "What does diversity look like in rural New York State?"  I led a partnership with Common Ground Health to analyze US Census and American Community Survey data for New York State and to create an intuitive interface for this data for use by our stakeholders. The NYSARH Diversity Dashboard provides map-based visualizations of data related to demographics, socioeconomics, and determinants of health for our rural coverage area. Ongoing and future work with this data will highlight areas of opportunity for NYSARH to expand its educational and health equity advocacy services and to new recruit members and board members from currently under-represented groups. 

Phase 2 (ongoing): We used the NYSARH Diversity Dashboard to generate a chartbook of insights (forthcoming) related to the diversity of rural people and places in New York State, and to identify opportunities for engagement and support. Using insights from the chartbook, we identified that in rural areas, people with disabilities face several challenges in equitably accessing services that support healthy, thriving futures. To better support education and advocacy needs related to people with disabilities living in rural areas, we are conducting virtual community consultations in June 2025 to understand NYSARH's potential role.

Phase 3 (ongoing): In the final phase of this effort, we have recruited Research and Policy Fellows to develop issue and policy briefs which tackle topics that are relevant to equity-seeking populations in New York State. Experts from across the country have partnered with NYSARH to develop educational modules for the Fellowship on topics related to health equity, state and federal policy, and effective advocacy.     

Funding/Support

This project has been funded by the National Rural Health Association (NRHA) through a State Rural Health Association Health Equity Pilot Grant (Subaward from HRSA/HHS/FORHP U16RH03702: Technical Assistance Pilot Award for Best Practices and Community Development) and subawards from NRHA MacKenzie Scott Health Equity Funding. 

Outputs

• NYSARH Diversity Dashboard 

• Product launch at the NYSARH Rural Health Symposium, September 2023 

• Presentation at AHI North Country Leadership Summit, September 2023

• NYSARH Diversity and Opportunity Chartbook (forthcoming June 2025)

Impact

• Provided data informing the NYSARH 2023-2025 Business Plan

Description

Rural populations in New York State are aging more rapidly than urban areas. The New York State Association for Rural Health (NYSARH) is addressing the advocacy and education needs of rural communities to effectively support older adults in several ways:

Project 1 (complete, pending report): New York State has worked to develop a State Master Plan for Aging. To reduce the potential for unanticipated consequences for rural New York, NYSARH aims to support rural implementation through sharing promising practices for age-friendly efforts in rural New York, and to discuss the implications of the New York State Master Plan on Aging for rural residents and communities. NYSARH showcased rural promising practices and innovations in an Innovation Fair in September 2024, and convened a State Summit on Aging in April 2025. Leveraging our existing relationships with NYS Office for Aging, AARP-NY and the Coalition of New York State Alzheimer's Association Chapters, we invited key system stakeholders involved in the support of older adults in rural regions of NYS (policy-makers, organization and community leaders) to participate in our one-day summit. Reporting is forthcoming and is expected to inform education and advocacy efforts for 2025 and beyond.

Project 2 (ongoing):  Older Adult Rural Mental and Behavioral Health Workforce Support Program (OARS). This comprehensive rural, older adult mental and behavioral health and workforce support program is designed to raise awareness, combat mental health stigma in rural communities and provide cultural education to increase the pipeline of professionals supporting the mental health needs of rural older adults. This project includes several goals: (1) Stigma reduction - Movie screenings and facilitated discussions: 'All the Lonely People'; (2) Online, in-person trainings: rural community and older adult Mental Health First Aid (subawards to rural AHECs); (3) Free, online trainings: rural mental and behavioral health supportive studies (CEUs for professionals); (4) In-person shadowing and 'MASH' camp experiences; (5) Community and rural employer engagement and support. A Research and Policy Fellow funded through this grant examines access to treatment for opioid use disorders in rural areas.

Funding/Support

Project 1 has been funded by the National Rural Health Association (NRHA) through a State Health Association Age Friendly grant (subaward from John A. Hartford Foundation). 

Project 2 is funded by the Mother Cabrini Health Foundation.

Outputs

• Innovation and Resource Fair held September 2024, Binghamton, NY.

• State Summit on Aging held April 29, 2025, Ithaca, NY. Report on proceedings is forthcoming.

Impact

• Informing the NYSARH 2025 Advocacy Cycle.

Description

The New York State Association for Rural Health (NYSARH) serves an advocacy and education role for rural health communities throughout New York State. In fall of 2022, I led the development of a Research and Policy Fellowship modeled on the NRHA Rural Health Fellows program. Fellows select a timely topic that is aligned with the annual policy priorities of NYSARH. During the first half of the program they research their issue and write a Research Brief. In the second half of the year, they identify policy levers and allies related to their issue and produce a Policy Brief. 

Funding/Support

This project is supported by New York State Association for Rural Health (NYSARH) We are seeking additional funding to support the further growth and development of the program. Fellows are supported through various grants.

Outputs

• 2025 (ongoing):

  • Samantha Ballas, MS3: Reducing Disparities in Stroke Outcomes for Rural New Yorkers 

  • Abby Duvall, MPH: Equitable Access to Opioid Treatment through Mobile Medication Units

  • Joshua Grove, PhD Candidate: Community Health Assessments, Community Health Improvement Plans, and Mental Hygiene Local Service Plans 

  • Grace Gugerty, MS2: Rural Emergency Department Aand EMS Education and Readiness for Obstetric Emergencies 

  • Sabrina Soto, MHA: Maternity Care Access in Rural New York

• 2023-24: 

  • Mitchell Brooks, MPH, Research and Policy Fellow: Access to PrEP in Rural New York. 

    • Issue brief: Pre-Exposure Prophylaxis for HIV Remains Inaccessible for Those Most in Need

    • Policy brief: Supporting HIV Prevention in Rural New York State 

  • Natalie Toro, MS3, Research and Policy Fellow: Diversifying the Rural Health Physician Workforce

    • Issue brief: Bridging the Diversity Gap in Rural Healthcare by Recruiting Underrepresented Minority Physicians 

    • Policy brief: Supporting Underrepresented Minority Physicians in Rural Residencies 

• 2022-2023: 

  • Gregory Forlenza, Research and Policy Fellow, The Mental Health Workforce Shortage in Rural New York State. Issue Summary, Issue Brief, Presentation Slides

Impact

• Provided data informing the NYSARH 2023-2026 Business Plan.

• Informed 2024-25 NYSARH policy cycle

Description

In 2021-22, I was named a National Rural Health Association Rural Health Fellow. Teammates Dr. Whitney Zahnd, Dr. Courtney Burgin and I were challenged to develop a policy brief identifying policy levers related to the rural health workforce and setting a five-year agenda for workforce policy research and advocacy.  

Funding/Support

This work was unfunded, but supported by the National Rural Health Association Rural Health Fellows program. We also acknowledge the support and contribution of Carrie Cochran-McClain, NRHA Chief policy officer.  

Outputs

• NRHA Policy Paper: Toward a Sustainable and Diversified Rural Health Workforce

• Presented to the NRHA Rural Health Congress in February, 2022

• Additional dissemination:

  • QVR Blog post

  • RHIHub

Impact

• Cited in the Center for Medicare and Medicaid Services (CMS) Advancing Rural Health Equity: Fiscal Year 2022 Year in Review 

• Informed the NRHA 2022 Policy Agenda

• Underpins the 2022 NRHA position paper, "Ensuring a Strong Rural Health Workforce" 

Description

From the earliest days of the COVID-19 pandemic it was clear that a huge impact could be expected on the health workforce. In response to a triple threat of increased volume of patients, increased acuity of illness, and increased workforce absenteeism, we sought to identify best practices from the existing literature as well as learn about new workforce strategies to address these workforce challenges. We suggest a three-part framework to increase the numbers of health workers, to increase the flexibility of the workforce, and to sustain workers in practice. 

This project collected data and curated knowledge through a diversity of methods. A rapid scoping review of the extant literature was performed to identify the readily available knowledge about health workforce responses to emergencies. An extensive review of Canadian "grey literature" - non academic literature reflecting other sources of knowledge, such as policy documents, white papers, and web pages - identified hundreds of suggested or implemented strategies related to the COVID demands on the health workforce. Finally, collaboration with our national and international partners and stakeholders resulted in a "crowd-sourcing" of practices from around the world. Our primary output from this work consists of a publicly accessible and searchable database of health workforce strategies. We encourage future work using this extensive resource.

I co-led this project along with Dr. Ivy Bourgeault. We worked with a talented team of undergraduate and graduate researchers including Mara Mihailescu and Asli-Oubah Fuad.

Funding/Support

This Canadian Health Workforce Partners project was supported by the Canadian Foundation for Healthcare Improvement (now Healthcare Excellence Canada). Mara Mihailescu is supported in part by funding from the Canadian Institutes of Health Research. Alison Coates is supported in part by funding from the Social Sciences and Humanities Research Council of Canada.

Outputs

• Coates, A., Mihailescu, M., & Bourgeault, I. L. (2024). Emergency responses for a health workforce under pressure: Lessons learned from system responses to the first wave of the pandemic in Canada. The International Journal of Health Planning and Management, 39(3), 906–916. https://doi.org/10.1002/hpm.3778

• Database of Health Workforce Strategies in Response to the COVID-19 Pandemic. The objective of the CHWN-CFHI health workforce innovations database is to hold searchable information on health workforce strategies that mitigate the effects of the COVID-19 pandemic for patients, populations and health workers. Made available online in August, 2020.

• Coates, A., Fuad, AO., Hodgson, A. et al. Health workforce strategies in response to major health events: a rapid scoping review with lessons learned for the response to the COVID-19 pandemic. Human Resources for Health 19, 154 (2021). https://doi.org/10.1186/s12960-021-00698-6.

• Canadian Health Workforce Network Webinar, September 2020: "Health Workforce Strategies to Help Ensure Optimal Supply & Health System Response to the COVID-19 Pandemic". Presented by Ali Coates and Mara Mihailescu with an introduction by Jennifer Zelmer and Ivy Bourgeault. Webinar slides. Webinar video. 

• Conference Poster: "Health Workforce Strategies in Response to the COVID-19 Pandemic". Mara Mihailescu, Alison Coates, Asli-Oubah Fuad, Tyra Jutai, Jade Sim and Ivy L. Bourgeault. New York State Association for Rural Health 2020 Annual Conference, September 14 -17, 2020 (Virtual).

• Conference Presentation: “Health Workforce Strategies in Response to the COVID-19 Pandemic” – presented by Mara Mihailescu at the Canadian Health Workforce Conference, December 2020. 

Impact

• Cited by Ziemann et al in their WHO report on Global Health Workforce responses to address the COVID-18 pandemic. 

• The conceptual framework proposed in this project has been adopted as a strategic framework for rural health workforce strengthening by the National Rural Health Association.

Description

I worked with Dr. Richard Fleet of Université Laval to analyze quantitative and qualitative data about rural hospital transfers in Canada.  The quantitative data were provided by the Canadian Institute for Health Information (CIHI) through consultation with the Rural Roadmap Implementation Committee (RRMIC). Qualitative data were collected by RRMIC staff and their analysis was provided to us. We were tasked with understanding, from these data, what we know about the transfers of rural patients and their return to their community. 

This project supported Action 11 from the Rural Road Map, a broader collaborative initiative between the College of Family Practice of Canada (CFPC) and the Society for Rural Physicians of Canada (SRPC).   

Funding/Support

This analysis was funded by RRMIC which, in turn, is jointly funded by CFPC and SRPC. Dr. Fleet and I were supported by a committee consisting of RRMIC members Dr. Ruth Wilson, Dr. Ivy Oandasan, and Carmela Bosco.

Outputs

• Report: "Report to the Rural Roadmap Implementation Committee: Rural Patient Transfer and Repatriation" September 2020. (unpublished)

• Presentation to the Rural Roadmap Implementation Committee: "Report on Transfers of Care" August 2020.

• Presentation at Rural and Remote Medicine Course: "Rural Transfers of Care" April 2021. 

Impact

• The findings formed the basis for the April 2021 Call to Action: An Approach to Patient Transfers for Those Living in Rural and Remote Communities in Canada

  • This call to action was made jointly by the CFPC, the SRPC, and 

  • This document was further endorsed by the Canadian Medical Association 

• Our findings inspired a "Podium" article by Ruth Wilson in the Canadian Journal of Rural Medicine: "Why COVID-19 could be a boon for rural patient transfers"

• The project, and the subsequent Call to Action, continue to inform the advocacy efforts of the SRPC. The SRPC National Summit on Equitable Access to Transport Care was held in Ottawa, ON in May 2023.

Description

Northwest Cares, a community coalition of health services organizations in northwestern Connecticut, asked what they might learn from the early phase of the COVID-19 pandemic to inform their response to an expected "second wave." In response to this need, I, along with my colleague Dr. Carrie Roseamelia, designed a community based participatory research project that was co-led by a steering committee of community partners: Lori Fedewa, Connecticut Office of Rural Health; Rick Lynn, Northwest Hills Council of Governments; Kevin O’Connell, The Geer Corporation; Gertrude O’Sullivan, Foundation for Community Health; and Julie Scharnberg, Northwest Connecticut Community Foundation. 

We collected data from community stakeholders within the northwest Connecticut region through qualitative surveys, focus groups, and key informant interviews. Our analysis yielded a set of challenges encountered during the first wave of the COVID Pandemic,  the region's organizational responses to those challenges. We discovered the organizational characteristics that enabled responses. We explored participants' views of collaboration and communication during COVID, and we heard about some "silver linings." Analysis of the data yielded five opportunities for system strengthening, along with concrete recommendations for action.

Funding/Support

This project was funded by the Connecticut Office of Rural Health with support from the Foundation for Community Health, NW Hills Council of Governments, Geer Village Senior Community, NW Cares and Northwest Connecticut Community Foundation. This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant H95RH00151, State Offices of Rural Health, $230,000. 

Outputs

• NW Cares: Learning from COVID-19 - Final Report and Executive Summary.

Impact

• Following the presentation of our findings to the NW Cares coalition, the community group engaged with the Connecticut State Division of Emergency Management and Homeland Security - Region 5 and incorporated our recommendations for system strengthening into their After-Action Report/Improvement Plan (AAR/IP).

• In direct response to our recommendation that systems be created to enhance multi-jurisdictional collaboration and coordination of emergency response, the Foundation for Community Health worked with the region's Public Health Emergency Planning workgroup to create the Northwest Network Community Collaboration. This network is designed to enhance communication capabilities of identified partners and allows a space for routine information sharing or emergency circumstances.