Attracting and Retaining the Physician Workforce: Use of the Community Apgar Tool
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1 Attracting and Retaining the Physician Workforce: Use of the Community Apgar Tool Ed Baker, PhD Professor & Director Center for Health Policy College of Health Sciences Boise State University David Schmitz, MD Professor & Chair Department of Family and Community Medicine School of Medicine and Health Sciences University of North Dakota Washington State Hospital Association & AWPHD Rural Hospital Leadership Conference Chelan, Washington June 26, 2017
2 Background How did we get here Why research? Boise State University: Ed Baker, PhD University of North Dakota: Dave Schmitz, MD Idaho Bureau of Rural Health and Primary Care: Mary Sheridan An intersection of, education and advocacy Practical knowledge, relationships, experience and investment Answering needs and necessary questions Applied research: Development of tools Partnerships with those with skin in the game 3RNet NOSORH
3 Apgar Score for Newborns Devised in 1952 by Virginia Apgar, an anesthesiologist, as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after birth Determined by evaluating the newborn baby on five simple criteria (Appearance, Pulse, Grimace, Activity, Respiration) on a scale from zero to two, then summing up the five values thus obtained
4 A New Response to the Same Old Problem What if there was a similar test for hospitals quick and repeatable with intervention measures on standby to assess readiness for recruiting physicians? Something new Something based on quantifiable data Something that incorporates the whole community Something that shows people on graphs and charts where they are and how to achieve their goals.
![A History of Community Apgar Year 1 (2007) Idaho Family Physician Rural Work Force Assessment Pilot Study [Published in the Journal of Rural Health] Year 2 (2008) Critical Access Hospital Community](/docs-images/80/81056537/images/5-1.jpg "Apgar Questionnaire (CAH CAQ) [Published in the Rural & Remote Health Journal] Year 3 (2009) Examining the Trait of Grit and Satisfaction in Idaho Physicians [Published in the Journal of the American")
5 A History of Community Apgar Year 1 (2007) Idaho Family Physician Rural Work Force Assessment Pilot Study [Published in the Journal of Rural Health] Year 2 (2008) Critical Access Hospital Community Apgar Questionnaire (CAH CAQ) [Published in the Rural & Remote Health Journal] Year 3 (2009) Examining the Trait of Grit and Satisfaction in Idaho Physicians [Published in the Journal of the American Board of Family Medicine] Community Apgar Program (CAP) Pilot for Critical Access Hospitals in Idaho Nursing Community Apgar Questionnaire (NCAQ) [Published in Rural & Remote Health Journal] Year 4 (2010) Community Health Center Community Apgar Questionnaire (CHC CAQ) [Published in the Rural & Remote Health Journal] Community Apgar Program (CAP) for Community Health Centers in Idaho Community Apgar Solutions Pilot Project Years 5-11 ( ) Expansion of the Community Apgar Program (CAP) for Critical Access Hospitals and Community Health Centers - Wyoming, North Dakota, Wisconsin, Alaska, Indiana, Utah, Montana, and Iowa (CAHs) - Maine (CHCs) Rural Community Variation in Physician Recruitment Readiness [Published in Journal of Health Science] Nursing Community Apgar Program (CAP) in Idaho Assessing Idaho Rural Family Physician Scope of Practice over Time [Published in the Journal of Rural Health] Year 9-11 ( ) Expansion of the Community Apgar Program and Nursing Community Apgar (CAP) to Australia.
6 Purpose of the Critical Access Hospital CAQ (CAH CAQ) A validated tool used to assess a rural community s assets and capabilities in recruiting and retaining family physicians. This should accurately correlate to historical communityspecific trends. Designed to be a real-time assessment tool providing guidance for the most helpful interventions at the present.
7 Purpose of the CAH CAQ (cont.) Presentation of individual CAQ Scores facilitating discussions with key decision makers in each community for specific strategic planning and improvements. The CAH CAQ can also be used to track a community s progress over time, similar to the clinical use of Apgar scores in newborns.
8 CAH CAQ Development The CAH CAQ Questions aggregated into five Classes Each Class contains 10 factors for a total of 50 factors/questions representing specific elements related to recruitment and retention of family physicians in rural areas Three open-ended questions Hospital and Community Support Medical Support Geographic CAQ Scope of Practice Economic
9 CAH CAQ Development: Class/Factor Examples Geographic Schools Climate Perception of Community Spousal Satisfaction Economic Loan Repayment Competition Part-time Opportunities Signing Bonus Scope of Practice Emergency Care Mental Health Obstetrics Administration Duties Medical support Nursing Workforce Call/practice Coverage Perception of Quality Specialist Availability Hospital and Community Support EMR Welcome & Recruitment Televideo Support Plan for Capital Investment
10 The Community Apgar Program (CAP) Year 1 of Program Participants mailed the CAH CAQ survey with consent form CAH CAQ surveys administered in separate structured one hour interviews for each participant CAH CAQ Board Reports Individual data from each critical access hospital reviewed with Board of Directors each year of the program Action plans developed in Year 1 for improvement in areas identified by the CAH CAQ State level results presented at state selected forum Year 2 of Program Second round of CAH CAQ surveys Year 2 Board presentation focuses on movement towards achieving improvement identified in Year 1
11 Use of the CAH CAQ This assessment allows for identification of both modifiable and non-modifiable factors and also may suggest which factors are most important for a community to address with limited available resources. The CAH CAQ may be used by communities to assess their relative strengths and challenges, the relative importance of CAQ factors, and to gain a better understanding of which CAQ factors are seen as most important from the physician pointof-view.
12 Making the most of the CAH CAQ Recruiting and Retaining Family Physicians: community self-evaluation prioritizing improvement plans advertising and interviewing negotiation strategies and contract construction
13 The CAQ Value Proposition Beyond Expert Opinion A new approach to the old problem of physician recruiting Self-empowering for the community: knowledge as power, not an outside headhunter Beyond physician recruitment to community improvement
14 Future of the CAH CAQ With further research and collaboration, this tool could also be used to share successful strategies communities have used to overcome challenges which may be difficult or impossible to modify (Best Practice Model). CAH CAQ surveys may be useful in identifying trends and overarching themes which can be further addressed at state or national levels.
15 Current Apgar Partners States Participating in the CAP States Interested in Implementing the CAP
16 State Level Information
17 Cumulative Score Class CAH Community Advantages and Challenges Cumulative Score Overall Administrator Physician Economic Hospital and Community Support Scope of Practice Medical Support Geographic Community Advantages and Challenges Class
18 Mean Score Top 10 CAH Community Advantages Mean Score 2.00 Overall Endoscopy, surgery Community volunteer opportunities Transfer arrangements Loan repayment Community need, physician support Employment status Religious, cultural opportunities Recreational opportunities Ancillary staff Call, practice coverage Top 10 Factors- Advantages
19 Mean Score Top 10 CAH Community Challenges Mean Score 2.00 Overall Spousal satisfaction Mental health Allied mental health Shopping and other services Climate Physician stability Perception of community Electronic medical records Administration Nursing Top 10 Factors- Challenges
20 Mean Score Top 10 CAH Community Importance Mean Score 4.00 Overall Spousal satisfaction Competition Perception of quality Income guarantee Call, practice coverage Loan repayment C-section Obstetrics Nursing Schools Top 10 Factors- Importance
21 Mean Score Geographic Class CAH Community Apgar Mean Score 8.00 Overall Administrator Physician Recreational opportunities Religious, cultural opportunities Schools Demographic, patient mix Access to larger community Social networking Perception of community Climate Shopping and other services Spousal satisfaction Geographic Factor
22 Mean Score Top 10 CAH Community Apgar Mean Score 8.00 Overall Endoscopy, surgery Loan repayment Community need, physician support Transfer arrangements Employment status Recreational opportunities Ancillary staff Call, practice coverage Perception of quality Religious, cultural opportunities Top 10 Factors- Apgar
23 Mean Score Bottom 10 CAH Community Apgar Mean Score 8.00 Overall Spousal satisfaction Mental health Allied mental health Shopping and other services Climate Physician stability Electronic medical records Televideo support Administration Payor mix Bottom 10 Factors- Apgar
24 Facility Level Information
25 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score Wyoming (All Sites) Baseline Carbon County Memorial Hospital Overall Apgar Geographic Economic Scope of Practice Medical Support Hospital and Community Support Community Apgar Class
26 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score for Geographic Class Wyoming (All Sites) Baseline Carbon County Memorial Hospital Access to larger community Demographic, patient mix Social networking Recreational opportunities Spousal satisfaction Schools Shopping and other services Religious, cultural opportunities Climate Perception of community Geographic Factors
27 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score for Economic Class Wyoming (All Sites) Baseline Carbon County Memorial Hospital Employment status Part-time opportunities Loan repayment Income guarantee Signing bonus Moving allowance Start-up, marketing costs Revenue flow Payor mix Competition Economic Factors
28 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score for Scope of Practice Class Wyoming (All Sites) Baseline Carbon County Memorial Hospital Obstetrics C-section Emergency room coverage Endoscopy, surgery Nursing home Inpatient care Mental health Mid-level supervision Teaching Administration Scope of Practice Factors
29 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score for Medical Support Class Wyoming (All Sites) Baseline Carbon County Memorial Hospital Perception of quality Physician stability Specialist availability Transfer arrangements Nursing Allied mental health Mid-level provider Ancillary staff Emergency medical services Call, practice coverage Medical Support Factors
30 Cumulative Apgar Score Hospital X Comparative Cumulative Apgar Score for Community and Hospital Support Class Wyoming (All Sites) Baseline Carbon County Memorial Hospital Physical plant and equipment Plans for capital investment Electronic medical records Hospital leadership Internet access Televideo support Hospital Community sponsored CME need, physician support Community volunteer opportunities Welcome and recruitment Hospital and Community Support Factors
31 Mean Score Hospital X Top 10 Apgar Factors across All 50 Factors Overall Physical plant and equipment Perception of quality Revenue flow Competition Recreational opportunities Transfer arrangements Loan repayment Income guarantee Access to larger community Endoscopy, surgery Top 10 Apgar
32 Mean Score Hospital X Bottom 10 Apgar Factors across All 50 Factors Overall Physician stability Electronic medical records Perception of community Emergency room coverage Part-time opportunities Signing bonus Nursing Climate Televideo support Perception of quality Bottom 10 Apgar
33 Cumulative Apgar Score Hospital X Top 10 Cumulative Apgar Variance Factors across All 50 Factors Social networking Nursing Signing bonus Hospital sponsored CME Hospital leadership Moving allowance Competition Revenue flow Plans for capital investment Transfer arrangements Top 10 Apgar Variance Factors
34 Cumulative Apgar Score Hospital X Bottom 10 Cumulative Apgar Variance Factors across All 50 Factors Inpatient care Call, practice coverage Perception of quality Climate Mid-level supervision Emergency medical services Shopping and other services Payor mix Physical plant and equipment Allied mental health Bottom 10 Apgar Variance Factors
35 Community Apgar Program Innovations in Iowa Iowa Hospital Association in partnership with Iowa State Office of Rural Health Client innovation requests Multiple physicians and administrators to participate Internet data collection Participation by trustee/board members One year Individual site presentations through distance presentations Webinar for State Level results presentation
36 Community Apgar Program Innovations in Iowa The Iowa Experience Recruitment through internet communications in partnership with Iowa Hospital Association Facility cost sharing Consent obtained electronically Data collected using Qualtrics (additional administrator and physician participation allowed, trustee participation) Apgar survey directions through 3RNet online educational material Facility and state level data presentations done remotely Trustee data analyzed separately
37 Community Apgar Program Innovations in Iowa Iowa Community Apgar Positives Use of technology to collect information 3RNet online educational materials Cost sharing with facilities Lower overall costs Additional input from physicians/administrators/trustees Iowa Community Apgar Challentges Technical analytical issues related to increase in participation of physicians and administrators Incorporation of trustee/board member data with physician and administrator data No Iowa expert No follow-up year two assessment
38 Selected Findings from the National Apgar Database
39 Selected Results Top 10 Apgar Factors Idaho (2016) North Dakota (2016) Indiana (2015) Montana (2015) Iowa (2015) Recreational opportunities Internet access Employment status Community need/physician support Loan repayment Transfer arrangements Income guarantee Competition Stability of physician Ancillary staff (Tie) Community volunteer opportunities(tie) Transfer arrangements Ancillary staff Competition Income guarantee Community need/ physician support C-section Emergency medical services Obstetrics Perception of quality Schools (Tie) Mid-level provider (Tie) Internet access Community need/ physician support Obstetrics Endoscopy/surgery Physical plant and equipment Employment status Emergency room coverage C-section Hospital sponsored CME Start-up/marketing costs (Tie) Schools (Tie) Community need/ physician support Perception of quality Employment status Competition Transfer arrangements Income guarantee Teaching Internet access Physical plant and equipment Recreational opportunities Schools Hospital leadership Perception of quality Income guarantee Emergency room coverage Ancillary staff Mid-level provider Emergency medical services Community need/ physician support Physical plant and equipment
40 Selected Results Bottom 10 Apgar Factors Idaho (2016) North Dakota (2016) Indiana (2015) Montana (2015) Iowa (2015) Mental Health Schools Shopping/other services Allied mental health Spousal satisfaction Electronic medical records Access to larger community Perception of community Obstetrics Nursing Spousal satisfaction Mental health Electronic medical records Shopping/other services Access to larger community Allied mental health Climate Emergency room coverage Specialist availability Payor mix Spousal satisfaction Social networking Shopping/other services Welcome and recruitment Allied mental health Perception of community Mental health Demographic/patient mix Climate Stability of physician Spousal satisfaction Allied mental health Mental health Shopping/other services Administration Nursing Climate Electronic medical records Access to larger community Social networking Mental Health Climate Spousal satisfaction Allied mental health Shopping/other services Part-time opportunities Access to larger community Electronic medical records Teaching Demographic/ patient mix
41 Community Apgar Program Next Steps Development of CEO/Administrator Apgar in 2017 Nurse Practitioner Apgar Physician Assistant Apgar Allied Health Apgar Expansion and further development of Apgar Solutions Additional use of technology
42 Questions? Edward Baker - ebaker@boisestate.edu David Schmitz - david.f.schmitz@med.und.edu
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