Innovations in Rural Health System Development

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H Iovatios i Rural Health System Developmet Recruitig ad Retaiig Maie s Health Care Workforce Amada Burgess, MPPM Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig

This series of briefs profiles iovative rural health system trasformatio models ad strategies from Maie ad other parts of the Uited States.

I preparig these briefs we cosulted experts, iterviewed key iformats, ad reviewed the professioal ad research literature to fid robust ad iovative models ad strategies that could be replicated i

1 H Iovatios i Rural Health System Developmet Recruitig ad Retaiig Maie s Health Care Workforce Amada Burgess, MPPM Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig health care providers, payers, ad other stakeholders to cosider how the curret delivery system might evolve. This series of briefs profiles iovative rural health system trasformatio models ad strategies from Maie ad other parts of the Uited States. The aim is to assist rural commuities ad regios to proactively evisio ad develop strategies for trasformig rural health i the state. I preparig these briefs we cosulted experts, iterviewed key iformats, ad reviewed the professioal ad research literature to fid robust ad iovative models ad strategies that could be replicated i rural Maie. PROMISING STRATEGIES: Rural-focused Medical Educatio Programs... 2 Oral ad Behavioral Health Workforce Developmet... 4 New Health Workers... 7 INTRODUCTION NOVEMBER 2016 Muskie School of Public Service Maie Rural Health Research Ceter Muskie School of Public Service Compared to the rest of the coutry, Maie has a robust per capita supply of physicias, urse practitioers, physicia assistats, urses, ad pharmacists. However, sigificat rural-urba disparities i provider distributio limit access to care i may rural areas of the state, where residets are older, have lower icomes, ad greater health eeds. Additioally, the agig of Maie s health care workforce is such that over the comig decade, early oe out of five health professioals curretly workig may eed to be replaced, ad i some occupatios icludig psychology ad detistry approximately oe out of three may eed to be replaced. 1 Recruitig ad retaiig health professioals i rural commuities is a log-stadig ad complex problem resultig from factors that iclude a urba-cetric medical educatio system ad medical traiig that

2 KEY FACTS about medical educatio i Maie frequetly does ot prepare providers for the uique challeges of workig i rural areas. I respose, health care workforce traiig programs, states, ad commuities i Maie ad across the coutry have developed promisig policies ad programs to icrease the likelihood that health professioals will be available to meet the eeds of rural residets ad commuities. This brief highlights iovatios uderway i Maie ad elsewhere i health professios educatio programs. The report also discusses iitiatives to expad the use of ew types of health workers, such as commuity paramedics ad commuity health workers, to expad the availability ad accessibility of health care i rural commuities. Nearly oe-third (30%) of Maie s primary care physicias graduated from a medical school affiliated with Maie Medical Ceter, icludig the Uiversity of New Eglad College of Osteopathic Medicie, Tufts Uiversity School of Medicie, ad the Uiversity of Vermot. 2 Maie-based medical residecy programs are a sigificat pipelie for Maie s primary care physicia workforce: over half (55%) of physicias i family medicie/geeral practice i the state completed their medical residecy i Maie. 2 PROMISING STRATEGIES Rural-focused Medical Educatio Programs What is medical educatio? To practice as a physicia i the Uited States a idividual must meet certai educatioal ad traiig requiremets. Physicias must ear a bachelor s degree, graduate from a four-year allopathic or osteopathic medical school, ad complete three to seve years of supervised professioal traiig i a residecy program, usually based at a hospital. I additio, physicias who wat to specialize may complete a oe to three year fellowship that offers additioal traiig i a sub-specialty such as gastroeterology or eoatology. KEY FACTS about medical educatio i Maie: Maie is home to oe osteopathic medical school (Uiversity of New Eglad College of Osteopathic Medicie) ad oe hospital-based allopathic medical school partership (Tufts Uiversity School of Medicie-Maie Medical Ceter Maie Track Program). Maie has four family medicie residecy programs. I additio to its family medicie residecy, Maie Medical Ceter has 13 residecy programs i specialties such as aesthesiology, pediatrics, ad surgery. Nearly oe-third (30%) of Maie s primary care physicias graduated from a medical school affiliated with Maie Medical Ceter, icludig the Uiversity of New Eglad College of Osteopathic Medicie, Tufts Uiversity School of Medicie, ad the Uiversity of Vermot. 2 Maie-based medical residecy programs are a sigificat pipelie for Maie s primary care physicia workforce: over half (55%) of physicias i family medicie/geeral practice i the state completed their medical residecy i Maie. 2 Maie raks 12 th atioally for retetio of physicias completig a medical residecy i the state. 3 PROMISING STRATEGIES AND MODELS Logitudial Itegrated Clerkships Redesigig medical educatio to recruit studets from rural areas ad provide them traiig experiece i rural settigs is a prove strategy for recruitig ad retaiig physicias i rural practice. Rural logitudial itegrated clerkships (LICs) are commo to Recruitig ad Retaiig Maie s Health Care Workforce 2

3 may rural-focused medical educatio programs. As opposed to block traiig programs that are comprised of a series of short rotatios i specific disciplies (psychology, obstetrics, surgery, etc.), a LIC is a prologed period of traiig durig the third year of medical school that gives medical studets the opportuity to provide care to a pael of patiets over time. Studies of idividual programs have foud that studets graduatig from rural-focused medical school programs are more likely to select a rural locatio for their practice. 4,5 EXAMPLE The Tufts Uiversity School of Medicie-Maie Medical Ceter Maie Track Program a partership betwee Maie Medical Ceter ad the Tufts Uiversity School of Medicie i Bosto, Massachusetts that seeks to grow Maie s physicia workforce offers its studets the optio of participatig i a ie-moth LIC at oe of te hospitals across the state, eight of which are located i a rural area. I additio to offerig a LIC, the program take several steps to ecourage studets to practice i Maie, icludig a targeted admissios process that favors Maie residets ad fiacial icetives for Maie studets. Rural Traiig Track Residecy Programs The rural traiig track (RTT) model is aother prove strategy for addressig physicia shortages i rural areas. RTTs geerally combie a year of traiig i a urba area with two years of traiig i a rural area, givig medical residets a opportuity to develop the skills eeded to practice successfully i rural areas. About twice the proportio of RTT graduates practice i rural areas after completig their residecy compared to family medicie residecy graduates overall (35% vs. 17.5% respectively). 6 EXAMPLE The Swift River Rural Traiig Track, a part of the Cetral Maie Medical Ceter Family Medicie Residecy Program, is the oly RTT i Maie, ad oe of oly two RTTs i New Eglad. Residets receive their iitial year of traiig at Cetral Maie Medical Ceter i Lewisto ad their secod ad third years of traiig at Swift River Family Medicie, a cliical departmet of Rumford Hospital, a 25-bed Critical Access Hospital located i Rumford, Maie. Sice its iceptio i 2005, 13 physicias have graduated from the Swift River RTT. Nie graduates cotiued to practice i a rural area after completig the program ad five stayed i Maie. Cosideratios for applicatio i Maie There is cosiderable evidece that multiple, coordiated strategies are eeded to successfully recruit ad retai doctors ad other health professioals i rural areas. This icludes state-level policy ad fiacial icetives as well as commuity level strategies to create a pipelie ito the health professios from secodary ad higher educatio to supportig rural-based health professios traiig programs. Maie is buildig a strog ifrastructure for rural-based health professio traiig that could be expaded with greater support for traiig sites that might be reluctat to support their cliicias ivestig time i traiig medical studets durig clerkships because the traiees may or may ot retur to the commuity after their required residecy. Recruitig ad Retaiig Maie s Health Care Workforce 3

4 KEY FACTS about the oral ad behavioral health workforce i Maie: Almost oe third of Maie s detists are 60 or older compared with 20 percet atioally. 1 Like Maie s physicia supply, the behavioral health workforce is cocetrated i urba areas. Sevety percet of the health care social workers ad 69 percet of metal health ad substace abuse social workers are employed i Cumberlad, Peobscot, ad Adroscoggi couties. 1 Physicias must have istitutioal support to take the time eeded to trai studets. If health systems support providers takig o the role of preceptor more studets will be able to experiece rural practice. Additioal resources o Rural Traiig Tracks ad Logitudial Itegrated Clerkships: The Cosortium of Logitudial Itegrated Clerkships: The RTT Collaborative: PROMISING STRATEGIES Oral ad Behavioral Health Workforce Developmet What is the oral ad behavioral health workforce? Maie s oral health workforce cosists of a variety of practitioers icludig detists, who must obtai a bachelor s degree ad the udergo four years of traiig at a detal school, ad positios with varyig educatio ad licesig requiremets such as registered detal hygieists, detal hygiee therapists, idepedet practice detal hygieists, ad expaded fuctio detal assistats. The behavioral health workforce is comprised of idividuals with varyig degrees of educatio ad traiig that provide metal health ad/or substace use disorder services, icludig: cliical, social, ad school psychologists; social workers; metal health couselors; ad substace abuse ad behavior disorder couselors. KEY FACTS about the oral ad behavioral health workforce i Maie: I August 2013, the Uiversity of New Eglad College of Detal Medicie, the oly detal college i Norther New Eglad, welcomed its iaugural class of 64 detal studets. Of the 64 studets, 24 were from Maie. The first class of studets will graduate i the summer of Maie s detists are uevely distributed, with Cumberlad, Keebec ad Peobscot couties maitaiig a disproportioately high share of employmet 68 percet of detists work i oe of those three couties but oly 42 percet of the state s residets reside i those couties. 1 Almost oe third of Maie s detists are 60 or older compared with 20 percet atioally. 1 Maie has fewer cliical, couselig, ad school psychologists per capita tha the atioal average ad early 70 percet of those psychologists are 50 or older. 1 Like Maie s physicia supply, the behavioral health workforce is cocetrated i urba areas. Sevety percet of the health care social workers ad 69 percet of metal health ad substace abuse social workers are employed i Cumberlad, Peobscot, ad Adroscoggi couties. 1 Recruitig ad Retaiig Maie s Health Care Workforce 4

5 PROMISING STRATEGIES AND MODELS Commuity-based Detal Educatio Detal traiig programs have icreasigly itegrated commuity-based educatio programs ito their curriculum. Oe such program exterships place detal studets ito rotatios i commuity sites such as commuity health ceters, mobile cliics, ad private detal offices durig their fial year of study. Rural extership placemets provide detal studets the opportuity to lear about the eeds of a rural commuity ad treat rural patiets. EXAMPLE The Uiversity of New Eglad College of Detal Medicie (College), the oly detal college i Norther New Eglad, aims to address the oral health access issues i the Norther New Eglad regio through a public health-focused, commuity-based curriculum. The College s curriculum icludes four semesters of public health-focused traiig i social ad behavioral sciece, epidemiology, ad the role of detistry i public health. Classroom study is augmeted by commuity outreach opportuities servig diverse populatios from pre-school through ed of life i a variety of settigs icludig jails ad homeless shelters. Studets begi seeig patiets i the o-campus Oral Health Ceter durig their secod year of their traiig a year earlier tha i most detal schools ad traiig culmiates i two 12-week exterships durig a studet s fourth ad fial year of traiig. Fourth year studets are placed amog 26 cliical sites icludig Federally Qualified Health Ceters, o-profit commuity health cliics, ad private practices that accommodate populatios with high eeds. Twety four of the sites are located i Norther New Eglad (icludig Aroostook ad Washigto couties i Maie) ad a vast majority of the sites are located i a Detal Health Professioal Shortage Area. The exteded legth of the extership program ad the rural ature of may of the cliics allow studets to better uderstad the roles of a detist i a smaller, high eed commuity. The College s admissios process targets studets with ties to orther New Eglad. Of its iaugural class of 64 studets, 24 were from Maie. Curretly, 43 percet of studets are from Norther New Eglad. The first class of studets will graduate i May 2017 ad the College plas to track where studets choose to practice after graduatio. EXAMPLE The Norther Maie Area Health Educatio Ceter (AHEC) ad the St. Apolloia Detal Cliic a pediatric detal cliic i Presque Isle that has a high proportio of low-icome patiets have collaborated to make Certified Detal Assistat traiig more accessible to practicig detal assistats i Aroostook Couty. St. Apolloia partered with Norther Maie Commuity College (NMCC) i Presque Isle to develop a detal assistat traiig program that combies both classroom ad hads-o istructio. The 100-hour course icludes chair-side procedures ad assistig i a variety of detal procedures at St. Apolloia Detal Cliic ad classroom work at NMCC. Fudig for the program was secured through a Maie Health Care Sector Grat from the Departmet of Labor i additio to fudig leveraged through the Norther Maie AHEC. Recruitig ad Retaiig Maie s Health Care Workforce 5

6 Pipelie programs A rural backgroud icreases the likelihood that a health care professioal will choose to practice i a rural area. Oe log-term approach to addressig shortages i the rural health care workforce is to itroduce rural secodary ad higher-educatio studets to health care professios at a early age, urture their iterest, ad provide opportuities for them to acquire skills that will help them eter a health professio. EXAMPLE I Nebraska, 71 of the state s 93 couties do ot have a psychiatric prescriber (psychiatrist, psychiatric urse practitioer, or psychiatric physicia assistat) ad 32 couties do ot have a behavioral health provider of ay kid. 7 Like Maie, Nebraska s behavioral health workforce is cocetrated i the state s urba areas. The Behavioral Health Educatio Ceter of Nebraska (BHECN) was established by the Nebraska Legislature i 2009 to improve access to behavioral health services i Nebraska through workforce developmet programs. BHECN s iitiatives focus o four areas: (1) developmet of a pipelie for behavioral health professios, (2) preparatio of studets i the provisio of behavioral health services, (3) traiig ad retetio of the existig behavioral health workforce, ad (4) evaluatio of ad reportig o the behavioral health workforce i Nebraska. BHECN s various recruitmet ad pipelie developmet efforts embrace a grow your ow approach that targets studets i Nebraska from high school through medical school. Due i part to BHECN-sposored psychiatry metorship activities at the Uiversity of Nebraksa Medical Ceter (UNMC) the umber of UNMC medical studets takig psychiatry electives steadily icreased from 9 to 69 betwee 2011 ad Recruitmet ito psychiatry residecy programs has also improved, with 9.68% of graduatig UNMC medical studets matchig i a psychiatry residecy program i 2015 more tha double the atioal average of studets matchig i a psychiatric residecy. I BHECN s fiscal years 2014 ad 2015, the orgaizatio provided free, i perso traiigs o topics such as Metal Health First Aid, trauma iformed care, ad compassio fatigue to over 3,000 idividuals workig i behavioral health, over 2,000 of which worked i rural couties. Cosideratios for applicatio i Maie Commuities with a shortage of health workers eed to parter with commuity groups, educatioal istitutios, govermets, ad others to come up with creative ways to recruit, trai, ad place rural commuity members i traiig programs that get them ito the health care workforce. Commuities eed to look at other models, such as Project ECHO which is profiled i the behavioral health-focused brief, to trai primary care physicias i rural areas to better address behavioral health issues of patiets. Additioal resources o oral ad behavioral health workforce developmet: BHECN Legislative Report: Report-2015-FINAL.pdf Behavioral Health Workforce Research Ceter: Rural Health Iformatio Hub, Rural Oral Health Toolkit: Recruitig ad Retaiig Maie s Health Care Workforce 6

7 PROMISING STRATEGIES New Health Workers KEY FACTS about ew health workers i Maie What are ew health workers? I a effort to address health care workforce shortages rural areas have expaded the use of ew types of health workers, icludig commuity paramedics ad commuity health workers. Maie s Commuity Health Worker Iitiative, part of the State Iovatio Model (SIM) Project, supports four commuity health worker pilots at DFD Russell Medical Ceters, MaieGeeral, Spectrum Geeratios, ad the City of Portlad s Public Health Divisio. I 2012, the Maie Legislature authorized the Maie Board of Emergecy Medical Services to establish commuity paramedicie pilot projects. Over the first two ad a half years of the program, the state s 12 commuity paramedicie pilot projects collectively made 3,755 commuity paramedicie rus. KEY FACTS about ew health workers i Maie Maie s Commuity Health Worker Iitiative, part of the State Iovatio Model (SIM) Project, supports four commuity health worker pilots at DFD Russell Medical Ceters, MaieGeeral, Spectrum Geeratios, ad the City of Portlad s Public Health Divisio. I 2012, the Maie Legislature authorized the Maie Board of Emergecy Medical Services to establish commuity paramedicie pilot projects. Over the first two ad a half years of the program, the state s 12 commuity paramedicie pilot projects collectively made 3,755 commuity paramedicie rus. PROMISING STRATEGIES AND MODELS Commuity Health Workers Commuity health workers are frotlie paraprofessioals that promote ad improve idividual ad commuity health by bridgig gaps betwee health care systems ad medically uderserved commuities. Commuity health workers provide cliets culturally appropriate health ad social services, iformatio o available resources, ad social support. Research has show that commuity health workers improve outcomes for cliets with a variety of chroic coditios icludig asthma, hypertesio, diabetes, ad cacer, 8 ad icrease use of prevetive services. 9,10 EXAMPLE Ketucky Homeplace is a robust, well-documeted commuity health worker iitiative servig 27 rural couties i easter Ketucky. Commuity health worker traiig for the iitiative icludes a 40-hour didactic traiig ad 80-hour practicum over the course of a three moth orietatio period. The didactic traiig covers topics icludig health coachig for chroic coditios, care coordiatio ad system avigatio, outreach ad advocacy, ad research. Sice its iceptio i 1994 the program has served over 100,000 rural Ketuckias at o charge. Cliets are typically poor ad have low levels of educatioal attaimet. 11 Several studies show the iitiative icreases patiet adherece to follow-up recommedatios ad kowledge ad awareess of prevetive health measures. 12,13 Commuity Paramedicie Commuity paramedicie fills health care gaps by expadig the role of paramedics ad emergecy medical techicias to provide i-home care ad educatio to idividuals who are ot eligible for, or have limited access to, home health services ad/or limited Recruitig ad Retaiig Maie s Health Care Workforce 7

8 trasportatio optios. Commuity paramedicie is a proactive approach to addressig the issues of hospital readmissios, frequet utilizers, ad use of emergecy departmets for routie health care. EXAMPLE The Licol Couty Commuity Paramedicie Pilot Project is a coordiated effort betwee the public Waldoboro Emergecy Medical Services, the quasi-muicipal Licol Couty Ambulace Service, ad the private Boothbay Regioal Ambulace Service; ad represetatives from LicolHealth, MaieHealth, Miles & St. Adrews Home Health ad Hospice, ad Licol Medical Parters. Referrals to the program come from physicias based at home health agecies, primary care offices, ad hospitals, icludig Togus VA Medical Ceter. After a referral is made the patiet is visited by a commuity paramedic withi hours. The average age of patiets visited is 80 years old, reflectig the agig populatio of Licol Couty ad the state. Cosideratios for applicatio i Maie Full adoptio of ew health worker models will require sources of paymet to support their services. Techical support may be eeded to help some providers develop strategies to icorporate ew health workers ito their practices ad delivery systems. Additioal resources o ew health workers: Maie EMS Commuity Paramedicie Pilot Program Evaluatio ems/documets/cp_muskie_report.pdf Commuity Paramedicie Program Hadbook Commuity Health Workers Toolkit REFERENCES 1. Leparulo P Health Occupatio Report. Maie Departmet of Labor, Ceter for Workforce Research ad Iformatio; April Skillma S, Stover B. Maie s Physicia, Nurse Practitioer ad Physicia Assistat Workforce i Seattle, WA: WWAMI Ceter for Health Workforce Studies, Uiversity of Washigto; September Associatio of America Medical Colleges, Ceter for Workforce Studies State Physicia Workforce Data Book. Washigto, D.C Qui KJ, Kae KY, Stevermer JJ, et al. Ifluecig Residecy Choice ad Practice Locatio through a Logitudial Rural Pipelie Program. Acad Med. 2011;86(11): Recruitig ad Retaiig Maie s Health Care Workforce 8

9 5. Zik T, Ceter B, Fistad D, et al. Efforts to Graduate More Primary Care Physicias ad Physicias Who Will Practice i Rural Areas: Examiig Outcomes from the Uiversity of Miesota-Duluth ad the Rural Physicia Associate Program. Acad Med. 2010;85(4): Patterso D, Schmitz D, Logeecker R, Adrilla C. Family Medicie Rural Traiig Track Residecies: Graduate Outcomes. Seattle, WA: WWAMI Rural Health Research Ceter, Uiversity of Washigto; February Behavioral Health Educatio Ceter of Nebraska. Behavioral Health Educatio Ceter of Nebraska: FY 2014 & FY 2015 Legislative Report. Behavioral Health Educatio Ceter of Nebraska; Ceters for Disease Cotrol ad Prevetio, Natioal Ceter for Chroic Disease Prevetio ad Health Promotio. Addressig Chroic Disease through Commuity Health Workers Kratz MJ, Coroel SM, Whitley EM, Dale R, Yost J, Estacio RO. Effectiveess of a Commuity Health Worker Cardiovascular Risk Reductio Program i Public Health ad Health Care Settigs. Am J Public Health. 2013;103(1):e Crump SR, Shipp MP, McCray GG, et al. Abormal Mammogram Follow-Up: Do Commuity Lay Health Advocates Make a Differece? Health Promot Pract. 2008;9(2): Uiversity of Ketucky. Ketucky Homeplace: Jauary 1, March 31, 2016 Quarterly Report. Ketucky Homeplace; Diga M, White C, Schoeberg N, et al. Effectiveess of a Itervetio for Adherece to Follow-up Recommedatios for Abormal Pap Tests i Appalachia Ketucky. Health Behavior ad Policy Review. 2014;1(1): Felter FJ, Ely GE, Whitler ET, Gross D, Diga M. Effectiveess of Commuity Health Workers i Providig Outreach ad Educatio for Colorectal Cacer Screeig i Appalachia Ketucky. Soc Work Health Care. 2012;51(5): The authors would like to thak iterviewees Jaya Bradshaw, Rebecca Carr, Norma Desjardis, ad Kare O Rourke for takig the time to speak with us about their work. Suggested citatio: Burgess A, Cobur A. Iovatios i Rural Health System Developmet: Recruitig ad Retaiig Maie s Health Care Workforce. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; November Recruitig ad Retaiig Maie s Health Care Workforce 9

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Innovations in Rural Health System Development

Innovations in Rural Health System Development H Iovatios i Rural Health System Developmet Maie s Behavioral Health Services Amada Burgess, MPPM Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig health care providers,