Health Care Personnel Education

Health Care Personnel Education A Report Submitted to The Joint Legislative Education Oversight Committee and The Joint Legislative Health Care Oversight Committee from The University of North Carolina Board of Governors, The State Board of the North Carolina Community College System, and The Department of Public Instruction March 2002 Prepared in response to: Senate Bill 166 The Studies Act of 2001, Sec. 8.11 CH SL 2001 491

This report was prepared by individuals from: The University of North Carolina The North Carolina Community College System The Department of Public Instruction The North Carolina Area Health Education Centers (AHEC) Program The Cecil G. Sheps Center for Health Science Research at The University of North Carolina at Chapel Hill The Council on Allied Health of North Carolina The State Education Assistance Authority The North Carolina Center for Nursing The North Carolina Board of Nursing 2

Table of Contents Executive Summary...5 Part I. An Overview of Health Workforce Issues in North Carolina...6 Introduction...6 Allied Health...10 Dentistry...14 Medicine...15 Mental Health...16 Nursing...17 Pharmacy...28 Public Health...29 Health Careers and Workforce Diversity...30 Part II. Report from the University of North Carolina...32 Introduction...32 Allied Health...36 Dentistry...45 Medicine...48 Mental Health...51 Nursing...56 Pharmacy...65 Public Health...67 Part III. Report from the North Carolina Community College System...76 Executive Summary...77 Existing Plans...78 Future Plans...79 Obstacles...79 Additional Plans...80 Number of Current Students Enrolled...81 Projection for Future Enrollment...81 Employment of Graduates...81 Reduction in Funding Impact...82 Attachment 1: Curriculum Degree Programs...86 Attachment 2: Continuing Education Courses...89 Part IV. Report from the Department of Public Instruction...95 Overview of Secondary Health Occupations Programs...96 Purpose of Secondary Health Occupations Programs...96 Current Initiatives...97 Enrollment and Follow-up Data...97 Program Expansion...98 Strategic Plan.../...99 Part V. Articulation...100 3

Appendices Appendix A: North Carolina General Assembly Senate Bill 166, Section 8.11 Health Care Personnel Education, Session 2001 Appendix B: Academic Program Inventory for the University of North Carolina Health Care Training Programs, 2002 Appendix C: UNC Distance Education Health Profession Programs Appendix D: New Health Care Training Programs Planned, the University of North Carolina, 2002 Appendix E: UNC Health Care Programs, Enrollments and Appendix F: Final Report of the 1997-Comprehensive Survey of Human Resources published the Council on Allied Health of North Carolina (February 1998) 4

Executive Summary This report was prepared in response to Senate Bill 166. In the first instance, the language of the Bill contemplates potential legislative studies of health care personnel issues. In addition, the Bill requires a report from the Board of Governors of the University of North Carolina, the State Board of Community Colleges, and the Department of Public Instruction that addresses the current and projected critical shortages of health care personnel and how the educational system can assist in the development of an adequate supply of appropriately trained health care personnel. The three educational sectors closely coordinate their activities and for this report agreed to prepare a single response to Senate Bill 166. We decided to share a common analysis of the problems, with each sector developing a distinct response, since degrees and degree levels are different. Nonetheless, our systems and programs are well articulated as is evident by the number of students who enroll in community colleges and continue their education in a health care field at public universities. Part I of this report provides an overview of health care workforce issues in North Carolina. This part of the report was prepared as a collaborative effort with data and analysis from the University of North Carolina, the N.C. Area Health Education Centers (AHEC) program, the Cecil G. Sheps Center for Health Science Research at UNC Chapel Hill, the Council on Allied Health of North Carolina, the State Educational Assistance Authority, the North Carolina Center for Nursing, and the North Carolina Board of Nursing. Using categories developed by the Sheps Center and AHEC, the report will consider developments in seven health areas: allied health, dentistry, medicine, mental health, nursing, pharmacy, and public health. Part II focuses on the University of North Carolina s health care programs and their plans and responses to health care personnel needs and issues. Part III focuses on the programs offered by the North Carolina Community College System and their analysis of issues and needs. Part IV, prepared by the Department of Public Instruction, presents the contributions of public schools to workforce development in the health care area. Part V is a reminder of the major efforts being made among all our institutions to clearly and smoothly articulate progress from degree level to degree level. Additional documentation and source material are provided in the Appendices. 5

Part I An Overview of Health Workforce Issues in North Carolina Introduction Over the past 40 years, the United States has experienced evolving imbalances in the diversity, geographic distribution, and specialty mix of its health care workforce. Today, virtually every health care discipline is adversely affected by problems associated with shortages in workforce resources. Some of these problems stem from decreased quantity either a shortage in absolute numbers or an uneven geographical distribution of health professionals; others reflect growing demand; while still others are due to deficiencies in a specialty/technical mix or competence. The current national workforce situation is complicated by the fact that most health profession areas are experiencing declining applicant pools and numbers of available workers. To be sure, examining the causes and possible solutions of shortages is a complex process. Factors that affect the supply of health professionals and those that affect retention in practice are interrelated. Demographic factors must be considered, since excesses or shortages can come about because the population either increases or declines at a faster rate than the rate of production of health care personnel. Health Care and Demographic Changes in North Carolina The health care shortages in North Carolina must be considered in the context of an expanding population and other demographic realities. The state is realizing unprecedented growth that outpaces the national average. One consequence is that composition of the state is becoming more diverse and bilingual. North Carolina s economic status varies widely among counties and in some of the more rural areas of the State there is a greater dearth of available health care professionals. As the population continues to change (e.g., growth, age trends, diversity, education levels, economic factors, others), the availability of health care services and professionals to provide services to the population will be affected. Demographics North Carolina s population will continue to exceed the national average in growth rate and will become more diverse. The state is outpacing growth and level of diversity projected by the Census Bureau in 1995. Although North Carolina ranks eleventh in total population, it was sixth in population increase in Census 2000 a 21.4 percent increase over its 1990 population. Only California, Texas, Florida, Georgia, and Arizona had greater growth. Nearly a quarter of North Carolina s population is 18 years old or younger (24.4 percent), and 12 percent of its population is 65 or older. 6

The state has a larger percentage of African American (21.6 percent) and American Indian (1.2 percent) residents than the national average (12.3 percent and 0.9 percent). It has a lower proportion of white (72.1 percent compared to 75.1 percent), Asian (1.4 percent compared to 3.6 percent), and Hispanic (4.7 percent compared to 12.5 percent) residents than the national average. North Carolina s population was projected by the Census Bureau to grow from 7,777,000 in 2000 to 8,840,000 by 2015 a 13.7 percent increase. This compares with a projected 12.9 percent increase for the total U.S. population. Figure 1 shows that North Carolina s Census 2000 population (8,049,000) exceeded its previously projected population for that year (7,777,000) by 272,000. As new population projections are developed based on Census 2000 data, it is probable that those projections will exceed previous projections for North Carolina. Figure 1. Projected Growth in North Carolina s Population (in 1,000s): 1995-2025 1 10,000 9,500 9,000 Actual Projected 8,840 9,349 8,500 8,000 8,049 ` 8,227 7,500 7,000 6,500 6,000 5,500 7,195 Previously 7,777 (projected) 5,000 1995 2000 2005 2015 2025 Figure 2 shows projected percentage changes in various age groups for North Carolina. Particularly noteworthy is the growth of the 5-17 age group from 1995 to 2000. These individuals (the baby boom echo ) are typically the children of the baby boomers born between 1946 and 1964. As they grow older, the traditional college age group (18-24) becomes the fastest growing age group during this first half of this decade. By the end of the decade, the 65 and older age group will be the fastest growing age segment as the baby boomers begin to reach retirement age and this has implications for planning health care services. 1 U.S. Census Bureau 7

Figure 2. Percentage Change in North Carolina s Population by Age Group: 1995-2000, 2000-2005, 2005-2015, 2015-2025 2 40% 0-4 30% 5-17 18-24 20% 25-64 65+ 10% 0% -10% 1995-2000 2000-2005 2005-2015 2015-2025 It is likely that North Carolina will become a more racially and ethnically diverse state than has previously been projected by the Census Bureau. Figure 3 shows North Carolina s 2000 population by racial and ethnic group as projected by the U.S. Census Bureau in 1995 compared with the actual 2000 Census findings. The white population is somewhat smaller than was projected, while the Hispanic population counted in Census 2000 already exceeds the number originally projected for 2025. Figure 3. Projected and Actual Comparisons of North Carolina s Population (in 1,000s) 3 7,000 6,000 5,851 5,805 5,000 4,000 2000 projected 2000 actual 3,000 2,000 1,738 1,738 1,000 0 379 96 114 121 94 100 Asian Black Hispanic Native Am. White As in the recent past, most of North Carolina s population increase is expected to come from in-state births and domestic in-migration, as opposed to international immigration. As various businesses and industries have relocated to North Carolina in the last decade, they have brought a number of employees from other states with them. More recently, North 2 Ibid 3 Ibid 8

Carolina has experienced substantial in-migration of workers, largely Hispanic, in laborintensive industries such as manufacturing and agriculture. Different regions of North Carolina will have differential rates of growth, with urbanized areas in the Piedmont or near interstate highways and coastal and mountain counties growing faster than more rural counties. Health Care Shortages in North Carolina In 1999, the Cecil G. Sheps Center for Health Care Services Research (Sheps Center) published A Twenty-Year Profile of Trends in Licensed Health Professions in North Carolina, 1979-1998, which analyzed trends in the supply and distribution of 16 licensed health professions. This report provides a valuable resource for educators, employers and policy makers throughout the state. The report examines the number of practitioners per 10,000 population in North Carolina and the United States for each of these professions and identified shortages in a number of areas (medicine, pharmacy, dentistry, and allied health). The Sheps Center has provided updated data for this report that compare North Carolina trends to U.S. trends in the seven health areas. The North Carolina Office of Rural Health utilizes data from the Sheps Center to identify counties in North Carolina that meet federal criteria for designation as a Health Professional Shortage Area (HPSA). An entire county or part of a county can be designated as an HPSA if it has an inadequate number of health professionals or a population with unusually high needs for primary care services. Figure 4 shows the counties in North Carolina that have been persistently designated as whole or part-county HPSAs. Twenty-one counties in North Carolina have been persistently designated as whole-county HPSAs and an additional 23 counties have been persistently designated as partcounty shortage areas. Figure 4. Persistent Health Professional Shortage Areas: North Carolina Counties 4 Persistent HPSA Designation Status (# of Counties) Whole County is PHPSA (21) Part of County is PHPSA (23) Not PHPSA Designated (56) 4 Persistent HPSAs are those designated as HPSAs by the Health Resources and Services Administration (HRSA) from 1993 to 1997, or in 6 of the last 7 releases of HPSA definition. Source: Area Resource File, HRSA, DHHS, 1998. Produced by: N.C. Rural Health Research and Policy Analysis Program, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. 9

Allied Health The allied health professions comprise a sizeable sector of the health care workforce. There are varying definitions of allied health, but in general they can be categorized as those health professionals associated with diagnostic, therapeutic, preventive, and organizational services. They are to be found in all health care settings as well as many education and rehabilitation facilities. In 1989, the National Institute of Medicine issued a report, Allied Health Services: Avoiding Crisis, that examined data from ten allied health occupations and predicted serious imbalances if corrective measures were not taken. In 1989 and 1990, the AHEC Program hosted two invitational conferences on allied health. One outcome of these two conferences was the realization that workforce planning in allied health required some primary data collection on supply and demand. A second major outcome was the creation of the Council for Allied Health in North Carolina in 1991. The Council now consists of 22 members who represent allied health professions, allied health educators, and major employers of allied health personnel. As a voluntary association, this Council has worked with AHEC, UNC, the NCCCS, the N.C. Office of Rural Health and others to provide the major sources of information about the allied health force workforce in North Carolina. Comprehensive Employer Surveys and Workforce Trend Reports The Council for Allied Health has published comprehensive reports on the allied health profession that have been used by educators, employers and policy makers to plan new academic programs as well as to plan off-campus programs for the past ten years. The Council is largely a voluntary association, and staff support has come from the Department of Allied Health at the University of North Carolina at Chapel Hill with additional assistance from AHEC, the Sheps Center, the UNC Office of the President, and employer and professional associations. In the 1990s, the Board of Governors Committee on Educational Planning, Policies and Programs began to study the need to address impending shortages of allied health care professionals in the state. Reports from AHEC and the Council for Allied Health provided compelling evidence of the need to increase the number of graduates in various fields especially in physical therapy, occupational therapy, and speech pathology. During the 1995 session, the General Assembly responded to these needs with a special provision in the expansion appropriations bill that provided funds to expand and strengthen existing programs and to accelerate the initiation of new allied health programs. Funds were also provided to support a collaborative distance-learning program in speech-language pathology and communications disorders. Additionally, the President recommended and the Board of Governors approved the allocation of $3,738,934 in the 1995-97 biennium to expand programs in physical therapy, occupational therapy, and speech pathology. The last comprehensive longitudinal survey of allied health professionals reflects trends to 1997. Since that time, the Council and the Sheps Center have published discipline-specific workforce 10

studies that are described later in this report. It is important to note that the 1997 document, the Comprehensive Survey of Human Resources published by the Council of Allied Health, provides the most recent comparative overview of trends over time in the allied health professions; however, it is dated. The absence of such longitudinal supply and demand workforce data hampers academic program planning for UNC and NCCCS as well as planning by policymakers and employers. The 1997 survey followed the 1993 and 1995 data collection format and requested information about 39 occupations across a wide range of significant employer groups. Additional employer groups were added to the 1997 administration (e.g., state and private commercial laboratories). The purpose of the trend report was clearly stated: This trend-line survey provides critical information on the demand for allied health and other health care personnel, and serves to build a database of at least 43 personnel categories across a wide range of employers to date. From this survey and future administrations, the Council will be able to identify significant changes in supply and utilization of any of the 43 personnel categories. Furthermore, the data will contribute to the development of policies and programs at the state, regional, and local levels intended to effectively address the manpower supply/demand situation. (1997 Comprehensive Survey, page iii.) Employers in North Carolina who were sent survey information included the following: 165...Hospitals 100...Health Departments 19...Developmental Evaluation Centers 121...Department of Public Instruction Facilities 353...Health Care Facilities-Nursing Homes 45...Rural Health Centers 24...Community Health Centers 750...Home Care Agencies 43...Psychiatric Hospitals, Mental Retardation Centers and Area Mental Health, Developmental Disability and Substance Abuse Centers. These surveys focused on important work-force issues such as full-time and part-time staff, the use of contract services, salaries, vacancy rates, recruitment time, strategies that employers use to address shortages, deterrents to recruitment and the surveys also focused on the comparative strategies for the retention of health professionals. For example, the following table shows important retention information. Employers were asked to list the five groups of employees that were most difficult to retain, as shown in Table 1. Total respondents: 576 (1995). 11

Table 1. Health Professions with Largest Employee Retention Difficulty (%) Occupation Response Nursing Aide/Assistant 36.5 Staff Nurse (RN) 25.9 Practical/Vocational Nurse 13.2 Physical Therapist 13.2 Occupational Therapist 13.0 Speech Pathologist 10.6 Social Worker 8.2 The survey also compared the use of various strategies to retain specific groups of employees as shown Table 2. Table 2. Strategies Used to Improve Employee Retention in Sample Health Professions Strategies Respondents Reporting Speech Pathologist Rural Urban Total Contract Services 48 44 92 Innovative Scheduling 15 8 33 Changes in Compensation 11 12 23 Programs Incentive Pay Benefit 9 13 22 Sign-up Bonus 8 9 17 Temporary Staff 6 11 17 Career Mobility 7 6 13 Restructuring Jobs 3 10 13 Scholarships/Forgivable Loans 3 5 8 Overtime 2 3 5 Student Employment 3 2 5 On-Call/Pool Staff 1 3 4 Foreign Recruitment 1 0 1 Staff Nurse (RN) Innovative Scheduling 49 46 95 On-Call/Pool Staff 45 33 78 Overtime 34 31 65 Changes in Compensation 32 32 64 Incentive Pay Benefit 31 29 60 Contract Services 25 24 49 Restructuring Jobs 28 17 45 Temporary Staff 23 21 44 Career Mobility 15 20 35 Scholarships/Forgivable Loans 22 13 35 Foreign Recruitment 13 15 28 Student Employment 15 7 22 Sign-up Bonus 10 11 21 12

The survey signaled that two categories of employees were experiencing critical shortages as shown in Table 3. Table 3. Two Categories of Critical Shortage in the Allied Health Professions 1997 1995 1993 Medical Technologist 1,036 1,116 1,568 (Clinical laboratory scientists) Radiologic Technologist 877 1,074 1,201 At the time of the survey, the highest full-time vacancy rates in reference to occupations were as follows: cytotechnologist (19.4%), dental hygienist (19.3%), occupational therapy assistant (17.8%), occupational therapist (17.3%), dentist (13.7% ), physical therapist (13.1% ), dental assistant (12.8%), nurse practitioner (11.6%), histologic technician (11.5%), speech pathologist (11.1 %), physical therapist assistant (10.8%), physician assistant (8.8%), medical assistant (8.0%), and nursing aide/assistant (7.6%). Of the fourteen occupations with the highest vacancy rates, five are of the rehabilitative occupations -occupational therapist and assistant, physical therapist and assistant, and speech pathologist. The three dental professions -dental hygienist, dentist and dental assistant- also reflected high vacancy rates, suggesting critical shortages. These professions were surveyed for the first time in 1997, thus external data needs to be correlated to survey findings to strengthen any inferences. As in the 1995 comprehensive survey, nurse practitioner and physician assistant posted in the highest vacancy rate category. Furthermore, these two professions are from within the scope of primary care mid-level practitioners. Of the remaining four categories, three occupations -cytotechnologist, histologic technician and medical assistant are all from within diagnostic disciplines, as compared to the above rehabilitative occupations. Thus, rehabilitative occupations, primary care mid-level practitioners, dental personnel and diagnostic occupations displayed critical shortages. Occupations depicting critical shortages, over an extended time period, may be the result of inadequate production of practitioners, increasing demand, or inability to substitute personnel. (1997 Comprehensive Survey, page xii.) Disciplinary Panel Studies Produced and Published by the Cecil G. Sheps Center at the University of North Carolina at Chapel Hill In March of 1999, the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill (Sheps Center) presented a proposal to the North Carolina Area Health Education Centers (AHEC) Program and the Council for Allied Health in North Carolina to establish advisory panels that would examine the North Carolina allied health workforce. The purpose of the proposed panel process was to review the best available statistical and administrative data, to discuss existing and emerging policies, and to construct a consensus statement on the need for, and supply of, allied health professionals in selected disciplines in North Carolina. The process was designed to take place under the joint guidance of representatives of the Sheps Center, the Council, and AHEC. The process envisioned a series of panels comprised of stakeholders including practitioners, employers, educators, and workforce planning experts for each allied 13

health profession. Physical therapy was chosen as the first profession and that analysis has been completed. Speech-language pathology was the second profession selected by the Council for study. Health information management has also been reviewed. In November 2000, the Board of Governors Committee on Educational Planning, Policies, and Programs met jointly to discuss health workforce issues. At that meeting, Board members requested additional information on the need for pharmacists in the state. Staff from the Sheps Center met with UNC Office of the President and AHEC staff and then prepared a proposal that AHEC partially funded to study pharmacy. Results from this study will be finalized in April 2002. Dentistry Nationally, the dental profession faces critical workforce supply and demand challenges. The number of dental graduates peaked in 1983 (5,700), declined through the late 1980s, and leveled off in the 1990s at 3,900 (ADA, Survey of pre-doctoral dental educational institutions: academic programs, enrollment, and graduates, 1999). As a result, in the 1990s, dental supply growth fell below overall population growth and that is projected to continue for the next decade. In 1999, according to the Sheps Center, there were 3.9 dentists per 10,000 population in North Carolina compared to the national rate of about 6 dentists, as shown in Figure 5. North Carolina began to experience a decline in the number of dentists per person in 1988. At the county level, the decline in providers has accelerated in the past ten years. Between 1980-1989, 43 counties experienced a decline in the number of dentists per person; between 1980-1989, 68 counties saw a decline in the number of dentists per person. In addition, there is a maldistribution of dentists in the state. There are four counties with no dentists in practice. The N.C. Office of Research, Demonstrations, and Rural Health Development estimates that 79 counties qualify as nationally recognized dental professional shortage areas. Thus, in many communities there are insufficient dentists to serve the population; a similar shortage exists for dental hygienists. Figure 5. Dentists per 10,000 Population, U.S. and North Carolina, 1979 to 1999 6.5 Dentists per 10,000 Population 6.0 5.5 5.0 4.5 4.0 3.5 3.0 US Dentists NC Dentists 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year 6.0 3.9 Sources: North Carolina Health Professions Data System, 1979 to 1999; HRSA, Bureau of Health Professions; US Bureau of the Census; North Carolina Office of State Planning Figures include all licensed active dentists. North Carolina population data are smoothed figures based on 1980, 1990 and 2000 Censuses. 14

Economic and demographic forces at the extreme ends of the population spectrum will influence the provision of dental services in the future. On the one hand, inadequate access to dental care is commonplace among children of families living in poverty. Nationally, among parents who feel that their children have unmet health care needs, 57 percent report the unmet need is for dental care. But there are only 47 actively practicing pediatric dentists in the state, and the number of pediatric dentists is declining. The lack of accessibility of dental services and the low utilization of dental services among low-income children contribute to the large number of young children with untreated dental disease. Not only do young children have particular problems accessing dental services, but people in institutional or group home settings, especially older adults, also have unique access problems. The aging of the general population will also have an impact on dental practice. Dental offices will provide care to a greater number of adults with increased education, substantial financial resources, higher expectations, and demands for maintaining and improving oral health. This group will expect to receive their dental care from practitioners trained in the latest scientific and technological advances in the field. The explosion of new information and technology will require practitioners to focus on continuing education in order to meet consumer expectations. Medicine Substantial progress has been made since 1972 in overcoming the problems of aggregate supply and geographic maldistribution of physicians in North Carolina. In 1971, the state was 36th in the nation in its ratio of physicians to population; in 1999 North Carolina stood 23 th (AMA, Physician Characteristics and Distribution in the U.S., 2001-2002 edition). In the 22 years between 1979 and 2000, the growth trends for all North Carolina physicians has closely paralleled national trends and the state s 75 non-metropolitan counties have shown greater improvement in the physician to population ratios than the comparable non-metropolitan counties in the rest of the United States (Sheps Center). During the 1993 session, the North Carolina General Assembly expressed its interest in expanding the pool of generalist physicians for the state by mandating that each of the state s four schools of medicine develop plans to expand the percentage of medical school graduates choosing residency positions in primary care. The plans submitted by the four schools reflect the unique missions and the strengths of programs in the schools. The plans also described similar initiatives to increase the percentage of graduates choosing careers in primary care. These included curriculum changes to emphasize primary care, increased use of community practices at teaching sites, and expansion of primary care residency positions across the state to ensure residency opportunities for those graduates who choose primary care specialties. In each case, the medical school plans for new generalist community-based initiatives built upon their 22-year relationships with the AHEC Program. These initiatives, as part of the 1995-2001 AHEC Plan, ushered in Phase II of the AHEC Program. In Phase I, medical education was decentralized--but largely to the AHEC hospitals and to selected physicians offices. In Phase II, the entire educational process moved even more into the community practice setting. This trend in undergraduate education, along with the expansion of primary care residency training, has led to a dramatic increase in the supply of primary care physicians in the state. In 2000, North 15

Carolina had 83 primary care physicians per 100,000 population, while nationally there were 78 primary care physicians per 100,000 population (Sheps Center). Figure 6 shows that the U.S. had an average of 25.5 physicians per 10,000 population in 1999, while North Carolina had an average of 19.8 per 10,000 in 2000. Figure 6. Physicians per 10,000 Population, U.S. and North Carolina, 1979 to 2000 26 25.5 Physicians per 10,000 Population 21 16 11 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year Sources: North Carolina Health Professions Data System, 1979 to 2000; HRSA, Bureau of Health Professions; US Bureau of the Census; North Carolina Office of State Planning Figures include all licensed active in-state non-federal non-resident-in-training physicians. North Carolina population data are smoothed figures based on 1980, 1990 and 2000 Censuses. US Physicians NC Physicians 19.8 A report of existing and future plans to address the workforce issues by the state s four medical schools and the AHEC program is being prepared. This report is submitted bi-annually to the Board of Governors of the University of North Carolina in response to General Statute 143-613 as contained in House Bill 230 in the 1995 session of the North Carolina General Assembly. Mental Health Mental health professionals include all those who assess and treat persons who have mental illness, developmental disabilities, and/or substance abuse diagnoses, or other significant behavioral problems requiring counseling. Included among mental health professionals are psychiatrists, psychologists, social workers, psychiatric nurses, Licensed Professional Counselors (LPCs), National Certified Counselors (NCCs), substance abuse professionals, school counselors/social workers/psychologists, and others. Many other health and social service professionals also provide mental health services and are often part of the Mental Health target audience. Examples are those working in Department of Social Services and Developmental Evaluation Centers, faith communities, juvenile justice, law enforcement and corrections, group homes and long-term care, day care, vocational rehabilitation, and others. Mental health professionals often work on interdisciplinary teams with these service providers. The largest employer of mental health professionals continues to be the public mental health system, largely within the N.C. Division of Mental Health, Developmental Disabilities, and 16

Substance Abuse Services. This system includes state psychiatric facilities, mental retardation centers, alcohol and drug rehabilitation centers, and thirty-eight area programs (commonly referred to as community mental health centers) covering all 100 counties. Other places of work for mental health professionals and their colleagues include hospitals, public health centers, rehabilitation facilities, substance abuse inpatient and outpatient programs, inpatient psychiatric units, schools, departments of social services, prisons, faith communities, private practice, nursing homes and other long-term care facilities, day treatment facilities, and others. Psychiatry remains a shortage specialty nationwide. The production of new psychiatrists is less than 50 percent of the need estimated by the Graduate Council on Medical Education. The shortfall is particularly acute for child psychiatrists where need outstrips demand by 15-fold. In North Carolina, the gap between the advertised need and supply for psychiatrists in rural and underserved areas appears to be growing again following a decade of improvement. Severe financial pressure from shortfalls in State Medicaid funding, contraction in private mental health treatment due to managed care pressures, and resultant cost-shifting to the public mental health system have all caused dramatic strains in public mental health. It may be expected that the North Carolina mental health workforce will enter a period of transition over the next two to five years, during which there will be considerable uncertainty regarding workforce size, capability, organization, and educational needs. The new system that will follow will likely have more focused priorities, and will require a workforce with new skills for community management of specifically targeted populations. The Supply of Nurses in North Carolina Nursing Registered Nurses (RNs) compose the largest group of health care professionals in the United States and also in North Carolina. In 2001, there were more than 92,496 licensed Registered Nurses (RNs) and of these 69,993 or 70% were employed in nursing. According to data available from the North Carolina Board of Nursing, 93% of the current working RNs are female and 7% male. The ethnic/racial background of the working pool is 87.4% White, 8.6% African American, 1.6% Asian,.7% Native American, and.6% Hispanic. Table 4 shows demographic, education, and placement information for Registered Nurses and Table 5 indicates the distribution of licensed (RN and LPN) and working nurses in North Carolina by county. Table 4. Current Registered Nurses in North Carolina, 2001 (Source: N.C. Board of Nursing) CURRENTLY LICENSED RNs CATEGORY NUMBER PRACTICE POSITION Currently Licensed 92,496 Public/Community Health 4,445 Administrator or Assistant 2,243 Currently Employed in Nursing 69,993 General Practice 2,985 Consultant 1,159 Currently Working in N.C. in Nursing 65,299 Geriatric 5,193 Supervisor or Assistant 5,788 Currently Working out N.C. in Nursing 4,694 OB/GYN 4,871 Instructor 1,777 Living in NC 64,248 Medical/Surgical 8,075 Head Nurse or Assistant 3,724 Living Out of State 5,745 Pediatrics 2,935 Staff/General Duty 42,684 Full Time 55,983 Psych/Mental Health 2,879 Nurse Practitioner 1,746 17

CURRENTLY LICENSED RNs CATEGORY NUMBER PRACTICE POSITION Part Time 14,010 AIDES 94 Nurse Midwife 152 Other Field Full Time 3,211 Cardiology 3,232 Clinical Specialist 1,170 Other Field Part Time 1,451 Critical Care 5,589 CRNA 1,844 Not Working in Any Field 5,987 Dermatology 93 Research 46 Retired 2,831 Dialysis 982 Other Position 7,533 Unknown Employment Status 9,023 Drug/Alcohol 201 EENT 184 SETTING OF EMPLOYMENT SEX Emergency Care 3,536 Hospital In-Patient 35,628 Male 4,783 Family Health 996 Hospital Out-Patient 5,958 Female 65,064 Neonatal 1,823 Long Term Care 4,977 Unknown Sex 146 Neurology 566 Solo/Group Medical Practice 5,334 Occupational Health 1,001 HMO or Insurance Co 788 RACE Oncology 1,740 Home Care/Hospice 4,370 White 61,206 Orthopedics 952 Public Clinic/Health Dept. 2,667 Black 6,041 Peri-operative 4,263 Mental Health Facility 1,348 Native American 502 Rehabilitation 1,226 Student Health Site 720 Hispanic 390 Transplants 140 Industry/Mfg.Site 692 Asian 1,103 Urology 245 Private Duty 297 Other Race 496 Other Practice 10,956 School of Nursing/Medicine 1,376 Unknown Race 255 Unknown Practice 791 Other Field 5,723 Field Unknown 115 RN DEGREE RN Diploma 10,881 RN Baccalaureate in Other 3,732 RN Doctorate in Nursing 155 RN Associate Degree 28,119 RN Masters in Nursing 4,397 RN Doctorate in other field 280 RN BS in Nursing 20,533 RN Masters in Other Field 1,895 RN Unknown Degree 1 Table 5. Licensed and Working Nurses in North Carolina by County, 2001 (Source: N.C. Board of Nursing) COUNTY CURRENTLY LICENSED & CURRENTLY WORKING IN NURSING FOR N.C. COUNTIES RN CURRENTLY LICENSED RN WORKING IN NURSING LPN CURRENTLY LICENSED LPN WORKING IN NURSING Alamance 1,195 926 280 184 Alexander 262 221 63 53 Alleghany 104 86 28 22 Anson 150 133 97 77 Ashe 387 308 114 81 Avery 218 167 82 57 Beaufort 920 707 199 137 Bertie 160 134 47 27 Bladen 230 184 115 80 Brunswick 537 363 281 186 Buncombe 3,065 2,328 771 567 Burke 1,014 827 187 133 Cabarrus 1,761 1,401 276 199 Caldwell 553 455 157 94 Camden 79 67 36 25 Carteret 597 441 244 176 Caswell 135 106 38 28 18

COUNTY CURRENTLY LICENSED & CURRENTLY WORKING IN NURSING FOR N.C. COUNTIES RN CURRENTLY LICENSED RN WORKING IN NURSING LPN CURRENTLY LICENSED LPN WORKING IN NURSING Catawba 1,233 994 214 142 Chatham 410 339 118 81 Cherokee 217 165 102 62 Chowan 121 106 66 54 Clay 99 74 48 34 Cleveland 906 721 328 250 Columbus 618 515 186 122 Craven 968 720 315 210 Cumberland 2,255 1,744 1,035 763 Currituck 115 90 43 28 Dare 253 165 62 32 Davidson 1,173 968 300 202 Davie 464 371 131 98 Duplin 379 307 140 96 Durham 4,100 3,072 839 569 Edgecombe 378 306 131 103 Forsyth 4,264 3,346 1,023 797 Franklin 341 267 130 96 Gaston 1,562 1,246 362 260 Gates 61 50 38 30 Graham 51 36 23 10 Granville 470 376 167 124 Greene 106 89 37 25 Guilford 4,437 3,402 690 480 Halifax 414 327 146 98 Harnett 466 392 200 140 Haywood 575 449 226 156 Henderson 1,170 912 259 191 Hertford 215 176 91 60 Hoke 130 105 95 65 Hyde 24 21 6 3 Iredell 1,453 1,150 239 165 Jackson 324 231 79 53 Johnston 963 797 291 208 Jones 83 61 42 29 Lee 517 413 213 156 Lenoir 632 512 243 181 Lincoln 525 409 135 100 Macon 296 210 94 57 Madison 206 158 91 69 Martin 206 166 58 40 McDowell 427 343 215 154 Mecklenburg 7,689 5,742 1,055 756 Mitchell 128 96 68 40 Montgomery 175 138 146 115 Moore 1,097 861 262 193 Nash 854 662 197 131 New Hanover 2,072 1,469 410 283 Northampton 158 121 83 59 Onslow 928 672 361 236 19

COUNTY CURRENTLY LICENSED & CURRENTLY WORKING IN NURSING FOR N.C. COUNTIES RN CURRENTLY LICENSED RN WORKING IN NURSING LPN CURRENTLY LICENSED LPN WORKING IN NURSING Orange 2,328 1,649 226 123 Pamlico 129 78 27 15 Pasquotank 303 240 120 87 Pender 307 245 121 95 Perquimans 104 74 49 37 Person 353 286 134 95 Pitt 2,263 1,708 282 190 Polk 211 161 61 47 Randolph 1,011 820 299 210 Richmond 424 334 159 127 Robeson 688 544 319 205 Rockingham 694 552 212 164 Rowan 1,276 1,009 332 244 Rutherford 505 410 229 171 Sampson 579 463 213 152 Scotland 243 192 112 92 Stanly 566 456 210 146 Stokes 431 363 161 140 Surry 824 678 258 189 Swain 116 89 38 23 Transylvania 315 228 79 52 Tyrrell 21 16 6 4 Union 1,310 1,036 254 185 Unknown 12,316 7,106 2,308 1,389 Vance 266 194 125 86 Wake 8,192 5,931 1,031 729 Warren 151 120 62 41 Washington 77 49 27 20 Watauga 386 295 89 53 Wayne 1,055 834 387 259 Wilkes 494 407 124 83 Wilson 654 521 188 131 Yadkin 379 320 146 109 Yancey 139 107 65 42 Totals 97,185 72,431 23,301 16,267 The Supply of New Nurses in North Carolina North Carolina has 62 nursing programs that prepare Registered Nurses at the diploma, the associate degree, and the baccalaureate level. Nine of these programs are offered through UNC at the baccalaureate level; 45 are associate degree programs offered by the North Carolina Community College System; five are baccalaureate programs offered through private colleges; and three are hospital based diploma programs. An additional baccalaureate program offered through the UNC system is the joint RN to BSN program offered by Fayetteville State University and the University of North Carolina at Pembroke, which provides access to baccalaureate education for the graduates of eleven community college nursing programs in the southeastern region of the state. The graph in Figure 7 depicts the number of North Carolina RN program graduates who have taken the NCLEX-RN exam in North Carolina each year since 20

1991. These are representative of students completing programs at all 62 nursing programs across the state that produce new registered nurses. From 1991 through 1994, there was an increase in the number of first-time test takers and this annual total reached an all-time high of 2, 936 in 1995, remained relatively steady and then declined to 2,395 in 2000. Figure 7. First-time North Carolina RN Graduates Writing the NCLEX: 1991-2000 5 3500 3000 2500 2000 1500 1000 First time NC Program Graduates # Tested 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2100 2277 2632 2900 2936 2843 2883 2780 2470 2395 Figure 8 shows the number of licensed practical nurses (LPNs) educated for the most part through the North Carolina Community College System that have taken the NCLEX-PN exam in North Carolina over the past 10 years. Note that in the early years (1991-93), the Board of Nursing reported that a number of the candidates were actually RN-educated. These cases have been removed from the annual totals for those years. However, subsequent annual reports, which serve as the source of this data, did not contain any reference to the education level of the candidates. It is possible that other years also contain RN-educated candidates. The annual counts in the graph are a conservative estimate of the number of LPN program graduates produced by North Carolina nursing education programs because it can be expected that not all graduates will sit for the exam in the same year they graduate. In addition, a small (but unknown) number may choose to take the exam in another state. Figure 8. First-time North Carolina LPN Graduates Writing the NCLEX: 1991-2000 6 1500 1000 500 0 First time LPN Program Graduates # Tested 1991* 1992* 1993* 1994 1995 1996 1997 1998 1999 2000 915 1077 1104 1126 1101 864 880 869 864 874 Data source: NC Board of Nursing Annual Reports, 1991-2000 Note: 1991-1993 counts have been adjusted by removing RN-educated candidates who sat for the NCLEX-PN in those years. 21

Understanding the Nursing Shortage According to reports from the program directors and faculty from the nursing programs at North Carolina Central University and the joint program at Fayetteville State University and the University of North Carolina at Pembroke, there is no simple explanation for the current nursing workforce shortage in the state and nation. The shortage is not a replication of the shortage of the 1980s. The shortage is a global concern and nursing numbers have declined in the United States, Europe and in many developing countries. As a result of the complex and interrelated causes of the current shortage, short-term strategies might result in minimal results. The complexities and extensiveness of the current and impending shortage will require innovative and multiple strategies and solutions such as regional partnership between educators and employers that focus on professional career path development to retain well prepared Registered Nurses with Bachelor of Science as well as graduate degrees. The nursing shortage in this millennium is a product of declining enrollment in nursing programs, changes in the work environment that result in low retention for some employers, the evolution of new opportunities for nurses who have transferable skills as well as the aging of the experienced nursing workforce. Efforts to ameliorate the nursing shortage must emerge from an understanding of the context in which it occurs. There are important factors contributing to the shortage, including: 1. Greater in-patient acuity with fewer RN staff nurses. The creation of unlicensed personnel groups to deliver care usually exacerbates a shortage situation. Patients today have shorter hospital stays requiring greater assessment, treatment, and discharge skills. These developments have increased the demand for baccalaureate prepared nurses. However, enrollment in baccalaureate programs is in decline, as are enrollments in many entry-level health programs. According to the American Association of Colleges of Nursing, baccalaureate enrollments decreased by 4.6% in 1999 and 2.1% in 2000, the fifth and sixth consecutive drops. 2. Aging faculty and aging practicing nurses. By 2010, more than 40% of the nursing workforce will be over 50 years of age and by 2020, the demand for nurses will exceed the supply by 20%. A vast exodus of nurses from the workforce could occur within the next two to ten years as a result of retirements. Lack of faculty will hinder educational programs efforts to provide a pool of replacements. Fewer faculty also affects the expansion of the knowledge base for nursing practice. Their participation as professional leaders who help shape health and education policy will also be limited. 5 Data source: N.C. Board of Nursing Annual Reports, 1991-2000. Chart created by Linda Lacey, North Carolina Center for Nursing. 6 Ibid. 22

3. The number of elderly in the population is growing rapidly. Chronic illnesses and the need for more health care services will also escalate requiring greater numbers of nurses. 4. The demographics of nursing students and the nursing workforce does not reflect the population. There are currently 2.6 million registered professional nurses, an increase of 5.4% since 1996. This is the lowest increase in the total population of RNs since these data have been reported. Of the 2.2 million employed RNs, 1.5 million are full-time employees. Overall, 94.6% of all nurses are female and 87% of all nurses are white. The population in North Carolina is becoming more diverse. Nursing should reflect that diversity. 5. Career options have changed for nurses. Today, nurses enjoy a wide variety of career choices. They can pursue many competitive, attractive, lucrative careers that were not available to the baby boomers. Nursing competes with law school, medical school, dental school, corporate and government opportunities for academically talented students. Trained nurses find suitable employment as researchers in pharmaceutical and insurance companies; others are employed as health policy-makers and administrators. 6. Nursing graduates enter a changed work environment. Health care facilities have downsized staff, combined units, instituted mandatory overtime and increased patient workloads. As a result, many nurses have left the profession. The nurse shortage makes retention harder. 7. Employment in a shortage environment increases job stress. Any attempt to address the shortage must include assessment and surveys of the work environment, especially hospital environments where approximately 60 of registered nurses are employed. Many nurses experience dissatisfaction with their jobs, the quality of patient care delivery, and the lack of training of supervisors and administrators. North Carolina hospitals that have retention rates should be well publicized throughout the state. The North Carolina Hospital Association is surveying hospitals throughout the state to assess factors that improve retention. 8. The image of what nurses do has not kept pace with the actual role of the professional nurse. The critical contribution of nurses to health care is still one of the best-kept secrets in the industry of health care. In order to increase the supply and retention of nurses in North Carolina, this role needs to be clearly understood. 23

Understanding the Nursing Shortage: Data from the North Carolina Center for Nursing The 2000 vacancy rate of 8.4% for Registered Nurses (RNs) in N.C. hospitals was one of lowest in the country, according to a 2001 report from the American Hospital Association. However, with patient acuity levels at an all time high, we can ill afford to be complacent regarding vacancies. Hospitals continue to be the major labor market for RNs, employing 58.8% of North Carolina s RN workforce in 2000. Nursing homes and physician offices employ the majority of Licensed Practical Nurses (LPNs). The N.C. Center for Nursing 2000 Employer Survey suggests that urban hospitals, located in areas where there are a growing number of opportunities for Registered Nurses, are experiencing a greater crunch, on average, than their rural counterparts. Compared to 1996, when specialty nurses were the most difficult to recruit, staff nurses in general medical-surgical areas were the most difficult to recruit in N.C. hospitals in 2000. In long-term care facilities and home care agencies, the frontline workforce crisis is the recruitment and retention of nurse aids. The population of RNs in the workforce has increased at a greater rate than the growth of the state s population as a whole. There is growing concern about the future nursing pipeline, owing to the average age of nurses in North Carolina (43.3 for RNs and 45.7 for LPNs in 2000). The aging of our nursing workforce, combined with a growing number of competing career choices, challenges us to prepare sufficient numbers to replace the nurses retiring in the next 10-15 years. The challenge is heightened by the projected increase in healthcare demand by aging baby boomers. There is also growing concern about the future infrastructure for preparing more nurses, especially in light of an evolving faculty shortage as the average age among N.C. nurse educators exceeds 49. The nursing shortage is not just about numbers; less than 35% of North Carolina s RN workforce held baccalaureate or higher degrees in nursing in 2000 and just over 11% represented racial and ethnic minorities. The LPN population, with 26% minority representation, is in greater parity with the state s population in general. Figure 9 shows that the U.S. had an average of 80.6 registered nurses per 10,000 population in 1997, while North Carolina had an average of 90 per 10,000 in 2000. It is apparent that North Carolina has steadily produced increasing numbers of registered nurses. While the number of nurses per 10,000 in North Carolina exceeds the national averages, the need for additional nurses is still severe. Many registered nurses are not practicing; some are not located where the shortages are greater. A variety of factors and issues influence the shortage of RNs and LPNs in North Carolina including burnout, inadequate professional development opportunities, vacancies in rural counties, an aging population, the need for a more diverse workforce, and others. According to the U.S. Department of Health and Human Services, too few young people are choosing careers in nursing, and the average age of registered nurses has increased substantially. In 1980, 52.9 percent of RNs were younger than age 40; in 2000, 31.7 percent 24

were younger than 40. In 1980, 26 percent of RNs were under the age of 30, but by 2000, less than 10 percent were under age 30. Figure 9. Registered Nurses per 10,000 Population, U.S. and North Carolina, 1979 to 2000 100 Registered Nurses Per 10,000 Population 90 80 70 60 50 80.6 US Registered Nurses NC Registered Nurses 90.0 40 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Sources: North Carolina Health Professions Data System, 1979 to 2000; HRSA, Bureau of Health Professions; US Bureau of the Census; North Carolina Office of State Planning Figures include all licensed active registered nurses North Carolina population data are smoothed figures based on 1980, 1990 and 2000 Censuses. Year Figure 10 shows that the U.S. had an average of 15.1 licensed practical nurses per 10,000 population in 1998, while North Carolina had an average of 21.8 per 10,000 in 2000. It is important to observe that there has been a steady decline in LPNs since 1998. Figure 10. Licensed Practical Nurses per 10,000 Population, U.S. and North Carolina, 1979-2000 Licensed Practical Nurses per 10,000 Population 28 26 24 22 20 18 16 14 12 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Sources: North Carolina Health Professions Data System, 1979 to 2000; HRSA, Bureau of Health Professions; US Bureau of the Census; North Carolina Office of State Planning Figures include all licensed active licensed practical nurses. North Carolina population data are smoothed figures based on 1980, 1990 and 2000 Censuses. Year 25 US Licensed Practical Nurses NC Licensed Practical Nurses 15.1 21.8

Nursing Faculty in North Carolina SREB s Red Alert In order to address the developing shortage of nurses in North Carolina it will be necessary to increase enrollments in the state s nursing education programs. However, nurse educators, as a group, are rapidly moving toward retirement age and nursing programs are already finding it difficult to fill faculty vacancies. SREB has issued a Red Alert that the nursing faculty shortage has become worse in the 16 SREB states. The 2000-01 survey of all SREB states reviewed the critical situation facing nursing education programs at all levels in the region. Linda Hodges, president of the SREB Council on Collegiate Education for Nursing says that the survey revealed a bleak picture about the supply of nurse educators and projections for the future. Moreover, the study concludes: Without enough well-prepared nurse educators to teach, this region cannot ensure the health of its residents. The survey focused on resignations, retirements, and a smaller pool of graduates prepared to be nurse educators. The most disturbing aspect of the red alert is that North Carolina ranks high in several categories, as shown in Table 8. The 16 SREB states: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. Table 8. Southern Regional Education Board Nursing Faculty Shortage Alert Of the 16 SREB States: Resignations States with more than 50 nursing faculty resignations in 2000-01: Texas North Carolina Tennessee Florida Retirements States with more than 50 expected nursing faculty retirements in 2002-06: Texas Florida North Carolina Mississippi 133 84 79 72 Faculty Positions Number of unfilled nursing faculty vacancies in 2000-01 (Top Six States): Texas Tennessee Georgia Florida Alabama North Carolina 58 35 34 32 31 28 Faculty Positions Institutions reporting insufficient numbers of faculty for undergraduate and graduate nursing programs in 2000-01 (10 or more): Texas Florida North Carolina 17 institutions 12 institutions 10 institutions Figure 11 was prepared by the North Carolina Center for Nursing to project the future supply and demand for nurses. The NSM model line suggests that the available supply of RNs can be expected to exceed or match demand until about 2013 when that supply estimation drops below the demand line. We know that the NSM model makes some assumptions based on trends 26

occurring in the early 1990s that are no longer in effect in the nursing workforce. Therefore, this estimate probably exaggerates the supply over time. Figure 11. Supply and Demand Forecast for RNs in North Carolina: High/Low Supply Estimates Number of RNs 115,000 90,000 This estimate of future supply was developed by using North Carolina baseline data in the Nurse Supply Model developed by the Division of Nursing, Bureau of Health Professions. 65,000 This estimate of future supply is a linear trend based on the actual number of RNs in the nursing workforce in North Carolina during the years 1996-2000, calcualted from the RN licensure files. 40,000 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 North Carolina Center for Nursing, 2002 NSM Model Estimated RN Supply: 1995 Baseline BLS Estimated RN Demand for NC Trend based on Actual RN Workforce Numbers: 1996-2000 The trend-based estimation line, based on the actual number of RNs who reported being employed in nursing in North Carolina in the years 1996 through 2000, falls below the demand line around 2002 or 2003. However, there is a consistent under-reporting of employment in nursing among licensed nurses in North Carolina. Therefore, this estimation line is considered to be very conservative. Since no one model or methodology should be relied upon for forecasting future events, this technique of using multiple forecast methods allows us to assess what the future might hold by using a worst / best case approach. It is probable that neither supply estimation line is an accurate forecast of future supply of RNs in North Carolina. Instead, it is likely that the truth lies somewhere in between. The shortages projected for 2010 and 2020 are very different from the cyclical shortages that have occurred in the profession of nursing during the last 50 years. The coming shortage will be driven by fundamental permanent shifts in the labor market, which are unlikely to reverse in the next few years. 27

Pharmacy The profession of pharmacy may be distinguished by the fact that it is the only health science discipline to have shaped its future through rational planning and deliberate decision-making. Pharmacy has evolved from its product preparation focus prior to WWII, through its dispensing focus to its current clinical (patient care) focus. The profession maintains its preparation and dispensing roles as it moves to take greater responsibility for the entire medication use system including the outcomes of pharmacotherapy. The exponentially increasing availability of scientific knowledge and the corresponding increasing availability of important new drug therapy options, the increasing utilization of the U.S. health care system, increasing costs of health care, the high rate of medication related problems (many of which are preventable) and the poor rate of patient compliance with drug therapy regimens are some of the factors that have increased the need for pharmacists to take a more active role in medication use. To assure that the pharmacist is capable of assuming these roles and dealing with these issues, the profession has moved to the six year Doctor of Pharmacy (Pharm.D.) program as its entry program. The transition process has been phased in nationally among the 81 schools of pharmacy, where curricular changes added one to two years to the degree requirement. A recent Health Resources and Services Administration (HRSA) report, A Study of the Supply and Demand for Pharmacists concludes that there is a national shortage and that each employment sector for pharmacists has shown evidence of increasing demand for pharmacists with increasingly demand in one sector affecting the supply of pharmacists available to other sectors. In addition, the pharmacist practicing today provides a much broader range of services than was offered even ten years ago. The profession has embraced the concept of pharmaceutical care, which extends the pharmacist s role to providing medicine therapy that continues through to the goals of improved patient outcomes. Pharmacists are engaged in efforts to improve the quality of the drug use process and to identify ways to reduce medication errors. Some of the market pressures contributing to a current or future shortage may well be short-term pressures subject to volatility in market strategies and expanding access to alternative dispensing models. This has led to contradictory claims of a surplus of pharmacists only several years ago and a shortage at this time. Examining the ratio of pharmacists per 10,000 population over the past 22 years reveals four different trend periods: rapid growth from 1979-1990; a slight decrease from the existing upward trend in 1991 and 1992; a holding steady period from 1993-1997; and then a marginally increasing supply since 1998, as shown in Figure 12. 28

Figure 12. Pharmacists per 10,000 Population, U.S. and North Carolina, 1979 to 2000 10 Pharmacists per 10,000 population 9 8 7 6 5 4 US Pharmacists NC Pharmacists 6.9 8.6 3 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Sources: North Carolina Health Professions Data System, 1979 to 2000; HRSA, Bureau of Health Professions; US Bureau of the Census; North Carolina Office of State Planning Figures include all licensed active pharmacists. North Carolina population data are smoothed figures based on 1980, 1990 and 2000 Censuses. Year Since there is relatively limited data available to assist assessment of the adequacy of the pharmacy workforce in North Carolina, the AHEC Program in association with the Sheps Center for Health Services Research at UNC Chapel Hill is currently undertaking a study, at the initiation of UNC, of the state s current and projected supply and demand for pharmacists. The final pharmacy workforce study, which will be presented to the UNC Board of Governors, will be available in April 2002 and will assist educational planning and health policy. Preliminary reports from the study document a shortage. Pharmacy workforce stakeholders in North Carolina report unfilled vacancies, rising compensation, difficulty in recruiting and retaining faculty and AHEC preceptors, declining applications to pharmacy schools in past years and job/role dissatisfaction stemming from increased pressure to fill more prescriptions with fewer resources and little time for patient counseling and disease management. It is difficult to definitively link cause and effect, but a number of important workforce imbalances exist that may be contributing to, or exacerbating the current situation. Strong population growth, the aging of North Carolina s residents, new drugs, new uses for existing drugs, prescription drug coverage by third-party payers and direct-to-consumer advertising have contributed to increased demand for prescription drugs demand pharmacy services. The study indicates an imbalance in the supply of, and demand for, pharmacists in the state. Public Health Public health can be defined as organized societal efforts to prevent disease and monitor and improve the health status of defined populations. The practice of public health encompasses a wide array of activities in public, private, and voluntary organizations, which apply scientific and technical knowledge to prevent disease, promote health and improve the health status of defined populations. The emphasis is on the health and well being of the collective membership rather 29

than on the health status of individuals within the defined population. In addition, the emphasis is on prevention rather than cure. Changes in the health system including new biological, environmental, and behavioral health threats as well as shifts in health care organization, financing, and delivery create imperatives for public health to expand and adapt its educational and research initiatives in order to respond to emerging health issues and health workforce needs. The challenges of the public health system are wrapped in the diversity of its programs and professional disciplines, and the need to make these function synchronously in order to deliver the best possible service. Public health has within it many disciplinary groups, including physicians, nurses, dentists, nutritionists, health educators, environmental health specialists, social workers, laboratory technicians, epidemiologists, biostatisticians, and veterinarians. It is particularly vulnerable to workforce shortages in those disciplines. It is widely believed that workforce shortages exist in public health although there is very little current data available to quantify the extent of that shortage. Many entry-level public health workers are inadequately prepared, while management positions are frequently held by workers with insufficient supervisory training in public health. In addition to the issue of under-qualified personnel, there are also indications of recruitment and retention problems once those personnel are brought up to the minimum qualification levels. Health Careers and Workforce Diversity UNC, the North Carolina Community College System, and the North Carolina AHEC Program have always accepted the challenging need and goal to recruit more minorities into health care professions. While some improvement has occurred, data continues to show that in all health professions, minority populations continue to be underrepresented relative to the overall population in the state, despite the high demand for health care professionals. While African Americans, Native Americans, and individuals of Hispanic origin account for approximately 10 percent of North Carolina s health care workforce, these same minority groups comprise over one fourth of the state s population. The discrepancies are often much greater in rural counties and among rural populations in the Piedmont and eastern part of the state. The rapidly growing Hispanic/Latino population has highlighted what has always been a hidden and often forgotten component of access to quality health care: cultural sensitivity and competence in the delivery of health care. Primary health care access can be improved through a better diversity of the health care workforce. The nation s population outlook for the next century shows the numbers of minorities increasing, and we can expect health care issues to remain at the forefront of concerns for those growing populations. It is imperative that there be a focus on underrepresented and/or disadvantaged groups in efforts to improve the recruitment, distribution, retention and utilization, of health care professionals in the state. If the challenge to provide high quality care to the un-served and underserved is going to be met, the pool of competitive underrepresented minority applicants must be expanded and cultural competence in the delivery of health care continues to be an important consideration. It is imperative that there is a strengthening of focus on increasing 30

minority representation in the health care workforce in an effort to improve the distribution, accessibility and quality of the state s health care professionals. While the population explosion being experienced by most minority groups creates concerns for the quality of health care available, that same population provides a relatively untapped source for health care personnel. According to a Healthy People 2010: National Health Promotion and Disease Prevention Objectives, by the U.S. Department of Health and Human Services, increasing the number of minority heath professions is viewed as a partial solution to improving access to care. Several studies have shown that underrepresented minority health profession graduates are more likely to enter primary care specialties and to voluntarily practice in or near designated primary care health workforce shortage areas. Despite considerable efforts to increase the number of representatives of racial or ethnic groups in health profession schools (medicine, dentistry, nursing, pharmacy, and allied and associated health professions), the percentage of such entrants, enrollees, and graduates has not advanced significantly and in some cases has not advanced at all since 1990. The targets set by Healthy People 2000 for such enrollment and graduation were not achieved, and achieving the revised targets by 2010 presents a significant challenge. Additional attention will need to be given to such efforts as providing financial assistance for underrepresented racial and ethnic group students to pursue health care degrees, encouraging mentor relationships, promoting the early recruiting of students from racial and ethnic groups before they graduate from high school, and increasing the number of racial and ethnic group faculty and administrative staff members in schools that train health care professionals. Other suggested approaches to improving culturally appropriate care for ethnic and minority populations include increasing cultural competency among all health workers and increasing the number of lay health workers from underrepresented racial and ethnic groups. Responding to Health Care Needs The educational partners of North Carolina, the University of North Carolina, the North Carolina Community College System, and the Department of Public Instruction, have crucial roles in preparing health care professionals to serve North Carolina citizens. Each sector is responsible for providing its part of the seamless programs of study that produce highly qualified health care professionals for our State. The North Carolina public schools provide the foundation as well as the skills and knowledge needed to be successful in postsecondary education settings, and the community colleges and the University provide critical workforce training and advanced-practice education for the health workforce of North Carolina. At the appropriate levels, community college and University programs are designed to provide in-depth study of the particular health care areas, real-life application training in clinical settings, and a solid background in the liberal arts and sciences that help our health care providers to work together in teams, become critical thinkers, attain the kinds of communication skills that will be effective in critical situations, and other skills that ensure the meeting of competency levels, licensure and professional requirements. 31

PART II Report from the University of North Carolina and the N.C. Area Health Education Centers (AHEC) Program Introduction Part I provides an overview of the workforce issues in the seven AHEC areas of medical practice. Part II provides information about the programs the University of North Carolina has in place to prepare students to meet the health care needs of our people. This part will follow the same organization as Part I and present these academic programs for the areas of allied health sciences, dentistry, medicine, mental health, nursing, pharmacy, and public health. In each of these seven areas, information is provided on the numbers and types of degree programs at UNC constituent institutions and the numbers of students enrolled in and graduating from these programs. Next, selected other responses are provided, followed by an analysis or summary of the most salient issues. Senate Bill 166 directs that attention be given to the following issues: 1. Numbers of current and projected students in and expected to complete health care training programs. In each of the seven health professions areas, charts are provided that show three-year UNC trends in fall enrollments (by type of degree) and total degrees conferred for each degree area in 2000-2001. More detailed information is presented in Appendix E where enrollment and graduation data are provided by UNC institution and by degree level within each institution. In each of the seven health care areas, deans and department chairs provide comments on projected enrollments and factors that would influence these enrollments. A summary of enrollment and graduation data for UNC is as follows: Enrollments in Allied Health degree programs declined slightly from Fall 1999 to Fall 2001 (2,294 to 2,215), with 985 degrees conferred in academic year 2000-2001. Enrollments in Dentistry programs were relatively stable (386 in Fall 2001), with 97 degrees awarded in 2000-2001. Enrollments in degree programs related to Medicine declined slightly from Fall 1999 to Fall 2001, from 956 to 928, with 226 degrees awarded in 2000-2001. Enrollments in programs that produce Mental Health professionals increased slightly from Fall 1999 to Fall 2001 (1,424 to 1,493), with 592 degrees in 2000-2001. Nursing enrollments have declined somewhat from Fall 1999 to Fall 2001 (3,011 to 2,841), with 1,272 degrees awarded in 2000-2001. However in the longer view, there has been a significant increase in nursing enrollments and degrees. Pharmacy enrollments have increased (600 to 635), with 157 degrees produced in 2000-2001; and Public Health enrollments have decreased (608 to 580), with 226 degrees in 2000-2001. 2. Where students are employed upon completion of programs. Graduates of UNC health care programs serve in every region of North Carolina in a wide variety of roles and settings ranging from rural health clinics to major urban hospitals. No standardized process exists for tracking graduates of health professions degree programs, but several examples can be given. 32

The UNC Chapel Hill School of Social Work notes that its graduates are employed in agencies across the state, including the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the Department of Social Services, the Developmental Evaluation Centers, day treatment facilities, faith-based organizations, juvenile justice, law enforcement, corrections, group homes, nursing homes and long-term care facilities, day care, vocational rehabilitation, state psychiatric facilities, mental retardation centers, alcohol and drug rehabilitation centers, hospitals, public health centers, rehabilitation facilities, substance abuse inpatient and outpatient programs, inpatient psychiatric units, schools, prisons, and private practice. For graduates of the East Carolina Brody School of Medicine (approximately 1,600), about half practice in North Carolina, including 400 in eastern North Carolina and 200 in rural counties. As a final example, the UNC Charlotte School of Nursing found the following employment distribution of its program graduates from 1995-1999: hospitals, 27 percent; medical centers and private practices, 26 percent; other health-related agencies, 20 percent; health departments, 10 percent; graduate school or public schools, 10 percent; nursing homes, 6 percent; and business, 1 percent. 3. A description of obstacles to realizing plans. Responses from schools and departments in the seven health professions areas and from AHEC address obstacles to realizing plans to educate future health care workers. Some of these obstacles include: faculty shortages (e.g., Nursing); lack of updated workforce data that would inform program decisions (e.g., Allied Health); declining applicant pools in some areas (e.g., Speech-Language Pathology); retention of professionals given competing career opportunities in many health fields (e.g., Pharmacy graduates attracted to the pharmaceutical industry); cost for additional clinical slots in select areas and competition for clinical placements (e.g., Nursing, Pharmacy, Allied Health); and declining scholarship support (e.g., Nurse Scholars Program). 4. Additional plans should resources become available. Plans to expand the number of health care professionals in North Carolina include initiatives in the following areas: planning new academic programs, expanding distance and electronic learning strategies, increasing scholarships for health care professions programs, increasing the number of students admitted to health care professions programs (including provision of additional faculty and facility resources needed to accommodate additional students), implementing additional aggressive recruitment strategies, and accelerating and expanding production of graduates through summer programs. Appendix B lists current degree programs by type and by UNC institution, and some of these programs could be expanded with additional resources. Appendix C lists currently authorized UNC distance education programs that deliver degree programs to working health professionals throughout the state (new distance programs are constantly being developed), and Appendix D lists new health-related degree programs that UNC institutions are planning. 5. Any reductions in funding to programs designed to train or retain health care personnel. Funding has not been reduced for UNC health professions programs other than those reductions and reversions required by the State to address budget shortfalls. As one example of these State-mandated funding cuts, health professions schools at UNC Chapel Hill have experienced these reductions so far in the current fiscal year (2001-2002): 33

Dentistry, $1,179,779; Medicine, $5,015,776; Nursing, $458,998; Pharmacy, $518,623; Public Health, $1,282,672; and AHEC, $1,119,934 for a total of $9,575,782. General budget cutting will have an impact on health related programs as is evident from this example. UNC Responds to Health Care Needs: Long-Range Plan, 2002-2007 The University of North Carolina is committed to proactively responding to the needs of the people of the state for access to quality health care. This commitment involves working collaboratively with stakeholders in the public sector and the health care community to plan and implement strategies to address identified shortages in the number and distribution of health care providers. UNC actively participates in a larger health care leadership network by: Developing high quality academic programs to prepare medical and health providers at the baccalaureate, first professional, and graduate levels; Educating and training physicians and various health care providers as well as preparing the vast majority of the undergraduate and graduate faculty that are needed by the community colleges and UNC s schools of medicine, nursing, public health, and allied health; Advancing knowledge and public service through effective teaching, research and public service through nationally recognized health and medical research centers and institutes; Supporting cutting edge research in the basic sciences such as biology and genomics that will help inform the application of science in health and medicine; Providing access throughout the state to continuing education programs that are needed to ensure that the health professionals are current and competent in their fields of practice; and, Working to increase the diversity of the health workforce by enhancing opportunities for students from underrepresented populations; Working to improve access to quality health care throughout the state. UNC constituent institutions respond to the health care needs of the state with an extensive inventory of academic programs in allied health disciplines as well as the traditional disciplines of health and medicine. This inventory includes competitive on-campus and distance learning programs: UNC s academic programs in medicine, pharmacy, dentistry, nursing, and public health adhere to high standards of quality to prepare competent, licensed professionals therefore these programs must include current knowledge as well as effective public service and cutting-edge research. Distance learning program offerings are available throughout the state in various disciplines such as clinical laboratory science, speech pathology, emergency medical care, pharmacy, 34

and with the assistance from AHEC, UNC campuses offer RN to BSN completion and MSN programs for Registered Nurses who want to study for advanced degrees while continuing to work in their local communities; UNC medical schools and health centers support recognized research centers and institutes such as the Lineberger Comprehensive Cancer Center at UNC Chapel Hill and the Telemedicine Center at East Carolina University. UNC health and medical centers sponsor interinstitutional programs and collaborate research efforts with public and private medical centers throughout the state. UNC Office of the President and the constituent institutions have formed collaborative agreements with the public universities throughout southeast region through SREB s Academic Common Market and Regional Contract program. These agreements enable these states to avoid unnecessary duplication and to share faculty expertise for highly specialized health and medical programs. Residents of North Carolina and other southern states are thereby given access and reduced tuition to enroll in health and medical programs that are not offered by a student s home state. A pivotal partner in UNC s ability to respond to the needs for access to quality care is the nationally recognized N.C. Area Health Education Centers (AHEC) program. AHEC provides an infrastructure of support that links on-campus medical and heath programs with underserved regions of the state. Current AHEC initiatives include: Increasing recruitment into health careers with an emphasis on a more diverse workforce; Providing support for expanding the capacity of the university system to enroll students by supporting preceptor and primary care training sites from medical, physician assistant, and nurse practitioner students; Supporting the health care workforce in efforts to maintain high levels of competency through continuing education and access to new developments in health and medicine; and, Supporting comprehensive approaches and solutions to critical workforce issues. The Cecil G. Sheps Center for Health Care Services Research (Sheps Center) and the North Carolina Center for Nursing are key partners in the UNC health leadership network. Both agencies provide important state workforce data as well as national trend analyses that enable the legislature, the Board of Governors, the Office of the President, the campuses and employers to make informed decisions health workforce and to develop strategic plans. UNC uses these data to plan academic programs, to assess the effectiveness of strategies, and to help identify resources that are necessary to accomplish health workforce objectives. Implications of Health Care Needs Current challenges to ensuring access to quality healthcare throughout the state are impacted by the changing demographic realities of North Carolina including a rapidly growing population. 35

Responsiveness in health care will require deliberate statewide planning and new strategies to address workforce shortages. The UNC academic community is working with partners in the health care community to develop and implement strategies to address projected shortages in nursing, pharmacy, dentistry, medicine and various allied health disciplines. Strategies that were used in the past such as the nursing scholarship program and articulation agreements to facilitate transfer are being re-examined to assess their effectiveness in addressing current challenges; UNC and state health agencies are working with employers to identify best practices and effective workforce retention strategies. UNC educators will need to continue to work closely with hospitals and other principle employers of medical and health practitioners to develop effective retention strategies especially in underserved areas and especially in entrylevel and specialized practices professions; Effective workforce planning involves the recognition of several factors: some sectors of the health workforce are aging, such as in nursing as younger nurses are sometimes employed as clinical laboratory scientists rather than in direct patient care; the state needs diversity in the workforce; and, the health workforce needs increased proficiency in Spanish in order to provide emergency and continued care for North Carolina s growing Hispanic and Latino populations; Educational challenges include a recognition of the fact that we cannot expand health programs and distance learning programs without additional faculty and acknowledging that some programs are experiencing declining applicant pools; Even as UNC prepares faculty and practitioners, the University also has to respond to changes in accreditation requirements and entry-level practice for professions such as physical therapy and physician assistant programs from baccalaureate to master s-prepared practitioners. UNC health and nursing programs have responded to legislative requests for additional primary care physicians, nurse practitioners and physician assistants. Responsiveness to higher standards of training requires significant changes in the preparation of faculty who must educate and train advanced practice students. UNC is a part of a larger network committed to providing collaborative solutions to complex challenges in the fields of health and medicine. Improving access to health care clearly involves a variety of factors including changes in health policies. UNC s primary response will continue to be in the development and delivery of competitive health and medical programs. UNC remains committed to ensuring that graduates of these programs are highly skilled to help meet the needs of the state for qualified health care providers. Allied Health In the Allied Health areas, the University of North Carolina offers academic programs of study in Gerontology, Communication Disorders, Audiology, Speech-Language Pathology, Speech and 36

Hearing Sciences, Dental Assisting, Dental Hygiene, Health Care Management and Administration, Health Information Management, Health Sciences, Physician Assistant, Emergency Medical Care, Nuclear Medicine Technology, Radiologic Therapy and Science, Cytotechnology, Clinical Laboratory Sciences, Environmental Health, Occupational Safety and Health, Human Movement Science, Music Therapy, Occupational Therapy, Physical Therapy, Recreational Therapy, and Vocational and Rehabilitation Services. Each year more than 1,000 students complete degree programs in the allied health areas, and in Fall 2001, there were 2,215 upper division undergraduates and graduate students majoring in these programs. Upper division undergraduates compose 45.4% of the total allied health enrollment; 51.1% at the master's level, and 3.5% at the doctoral level. Of the 74 allied health academic programs, 34 of them are offered at the baccalaureate level, 29 at the master's level, 6 at the doctoral level and there are also 5-one-year certificate programs. Two areas that have realized significant growth over the past ten years are UNC programs in occupational therapy and physical therapy. The number of students enrolled in occupational therapy programs has increased from 107 students in 1991-92 to 215 students in 2000-01, an increase of more than 100%. Most of the increase has been realized at the baccalaureate level, from 69 in 1991-92 to 155 in 2000-01(nearly 125% increase), and master s level enrollments increased from 38 students in 1991-92 to 60 students in 2000-01 (57.9% increase). The total number of degrees conferred more than doubled from 38 in 1991-92 to 79 in 2000-01. In physical therapy, licensure requirements shifted from the baccalaureate degree to master s level competencies. In 1991-92, there were 124 students enrolled in baccalaureate physical therapy programs (59 degrees conferred), 31 students in master s level programs (11 degrees conferred), and no doctoral programs were offered through UNC. In 2000-01, 36 students were enrolled at the baccalaureate level (25 degrees conferred), 214 at the masters level (123 degrees conferred), and 7 students in doctoral programs. The total number of enrollments and professionals entering the physical therapy profession has risen sharply through the ten-year period, from 155 students enrolled in the discipline in 1991-92 to 257 in 2000-01, an increase of 65.8%. The number of degrees conferred more than doubled from 70 (84.3% at the baccalaureate level) in 1991-92 to 148 (83.1% at the master s level) in 2000-01. In order to provide programs of study for professionals to upgrade skills and acquire licensure competencies, several allied health programs are offered through distance education strategies at off-campus sites and through technological means. Distance education programs are available in communication disorders, physician assistant, occupational health and industrial hygiene, and speech language pathology. To help meet the demand of providing more qualified health care professionals, the University campuses are planning two new baccalaureate programs in health care management and allied health and two doctoral programs in physical therapy and rehabilitation counseling and administration. 37

UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) ALLIED HEALTH Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) 30.1101 Gerontology Fall Enrollment 34 27 33 9 51.0201 Communication Disorders, General Fall Enrollment 316 248 245 128 51.0202 Audiology/Hearing Sciences Fall Enrollment.... 51.0203 Speech-Language Pathology Fall Enrollment.... 51.0204 Speech-Language Pathology and Audiology Fall Enrollment 354 329 299 155 51.0601 Dental Assistant Fall Enrollment.... 51.0602 Dental Hygienist Fall Enrollment 60 67 60 33 51.0701 Health System/Health Services Administration Fall Enrollment 436 450 459 163 51.0706 Medical Records Administration Fall Enrollment 53 48 43 25 51.0799 Health and Medical Administrative Services, Other Fall Enrollment 46 46 57 11 51.0807 Physician Assistant Fall Enrollment 49 59 38 23 51.0904 Emergency Medical Tech./Technician Fall Enrollment 29 39 40 13 51.0905 Nuclear Medical Tech./Technician Fall Enrollment.... 51.0907 Medical Radiologic Tech./Technician Fall Enrollment 26 24 29 8 51.1002 Cytotechnologist Fall Enrollment.... 51.1005 Medical Technology Fall Enrollment 144 131 159 49 51.2202 Environmental Health Fall Enrollment 96 77 57 42 51.2206 Occupational Health and Industrial Hygiene Fall Enrollment 81 92 85 22 51.2304 Movement Therapy Fall Enrollment 22 24 27 5 51.2305 Music Therapy Fall Enrollment 41 46 43 12 51.2306 Occupational Therapy Fall Enrollment 199 207 190 72 51.2308 Physical Therapy Fall Enrollment 223 197 186 118 51.2309 Recreational Therapy Fall Enrollment 55 96 101 57 51.2310 Vocational Rehabilitation Counseling Fall Enrollment 30 39 64 40 Total Allied Health 2294 2246 2215 985 74 programs (34-B; 29-M; 6-D) East Carolina University School of Allied Health Sciences Response The School of Allied Health Sciences (SAHS) at East Carolina University has nine departments, with the first seven being degree-granting (B.S., M.S., Ph.D.): 1) Physician Assistant (PA), 2) Physical Therapy (PT), 3) Occupational Therapy (OT), 4) Communication Sciences and Disorders (Speech-Language and Auditory Pathology), 5) Clinical Laboratory Science, 6) Health Information Management, 7) Rehabilitation Studies (Rehabilitation Counseling, Substance Abuse and Clinical Counseling, Vocational Evaluation, and Rehabilitation Services), 8) Biostatistics, and 9) Community Health. Based on Department of Labor statistics, employment demand in these various fields has been above average, and the need in rural parts of North Carolina is critical. 38

Methods of addressing these critical shortages vary by issues of student recruitment, increasing program size, and curriculum delivery. Recruitment of qualified applicants into the various departments has required a greater emphasis on marketing. SAHS has placed a strong emphasis on developing and maintaining an interesting, informative, and interactive web page. One aspect of this web page is the Allied Health Career Explorer that helps users identify and explore allied fields of interest. Since the installation of a web page counter on November 22, 2002, the SAHS home page has had 7,585 hits, demonstrating its value as a marketing and recruitment tool. The School has also developed new printed and CD-based marketing materials and has attended numerous school/university career day events to distribute these materials and talk with prospective students. Work with the Summer Ventures program through Eastern AHEC has received greater emphasis because of the potential to recruit a more diverse student population. In regard to increasing program size, the Department of Physician Assistant Studies has expanded its distance education enrollment from 12 to 20 students this year, increasing total on and off-campus enrollment to 50 students. The problems associated with increasing enrollment in all departments will be discussed in the next section. New or revised curriculums and programs have been established throughout the School. PA and OT are moving from the Bachelor s to the Master s level next year, Audiology and PT are planning on opening entry-level professional doctoral programs (e.g., DPT) in the near future. Two new programs have received permission to plan. The Department of Rehabilitation Studies has been approved to develop a Ph.D. in Rehabilitation Counseling and Administration and will focus a major part of its curriculum on training substance abuse and mental health counselors and administrators (also a critical need area in North Carolina). The Bachelor of Science in Allied Health (BSAH) program targeted to begin in the Fall 2003 is designed to meet several needs. The first is to provide AA and AAS community college graduates in health related disciplines with a Bachelor s degree in health services management so they can receive higher salaries, accept management positions, improve their overall knowledge of the health care system, and develop skills to function more effectively and stay on the job longer. Second, the BSAH degree will give students that are interested in one of the SAHS graduate programs (PA, PT, OT, CSDI) the opportunity to complete their graduate prerequisite requirements while gaining a better understanding of the broader healthcare system. The management skills learned will help them better mange their discipline-specific departments while working more effectively within an interdisciplinary health care environment. Nearly all departments in SAHS offer a distance education course(s) or degree. Physician Assistant Studies is the first and only PA program in the country to offer its didactic program over the web. The Department of Communication Sciences and Disorders offers a M.S. in speech pathology over the Internet as well. The BSAH will begin as a web-based curriculum to meet the educational needs of health care workers who are employed full-time and who cannot or do not want to leave their jobs to seek further education. Health care employers can now keep qualified workers who otherwise would have left to return to school. Obstacles to Realizing the Goals There are several obstacles that negatively affect the School s ability to grow in order to meet increasing health care shortages. 39

1. SAHS has run out of faculty office, classroom, and research space. The School currently uses six trailers to house three departments, and two additional departments have been moved a significant distance away to the Voice of America Site C to help alleviate the problem of overcrowding. The new School of Allied Health Sciences building will not be ready for occupancy until the early part of 1006, leaving SAHS with nowhere to grow until that time. The BSAH program is expected to add approximately 400 more students bringing the total enrollment to over 900. Although the BSAH is initially offering its curriculum over the Internet, as are other degree programs in the School, many clinical and laboratory courses do not lend themselves to a web-based format. In addition, the increasing numbers of new students wanting a campus experience will require classroom space, even though many of their courses will extensively use instructional technology. Growth in existing and new programs will not progress until new space is available. In fact, there is not an available office in the Belk Building for the new director of the BSAH program who will begin this Fall 2002. 2. Salaries needed to hire qualified allied health faculty falls behind other universities as well as health care settings where many potential faculty currently work. When the Department of Clinical Laboratory Science (a field with a critical employment shortage) tried to hire a required clinical chemist to replace a retiring faculty member, the Department and School was unable to meet the salary needs of the applicants. As a result, a Master s level clinical chemist was hired and is being given leave time to complete her doctorate part-time. The chair position for the Department of Physical Therapy has been open for nearly two years, and an increased salary to $100,000 has attracted no more than two qualified candidates. 3. Budget cuts have hindered current program expansion and new program growth since new funds are not available to: 1) hire additional faculty, 2) increase the operating budget to cover additional faculty workloads, and 3) create additional Graduate Assistantships needed to attract qualified students and support faculty research projects. East Carolina University Physician Assistant Program Response Existing and future plans to address the issues of shortage of Physician Assistants (PAs) is to recruit from medically underserved communities and then take the program to them. ECU has been doing that successfully for four years and has accepted our third cohort of students that will start in May of 2002. We are also looking at the possibility of working with the School of Social Work with the idea that we may offer a dual master s degree in PA and Social Work with additional work toward a PhD in Social Work. This will give PAs in medically underserved communities much needed mental health training and will also give Social Work medical training to afford them the opportunity to prescribe and to have a better understanding of the whole patient. We recently completed a project where we shared core courses with FNP students, PA students and CNM students from Duke School of Nursing and from ECU School of Nursing. This allowed us to share faculty to write curriculum and to share teaching responsibilities. This worked well and was cost effective. 40

We have worked with the ECU School of Social Work and have written a curriculum that we feel will satisfy the accrediting bodies of both disciplines and have students interested in applying once we are approved. Satellite PA Programs much like the programs in Georgia and Kentucky could be initiated with teleconferencing from our campus at ECU if we had more funding for Distant Education (DE) equipment. Satellites could be set up at remote locations like Elizabeth City State, Appalachian, or other colleges and universities within the system. After we receive approval as an entry level master s PA Program the undergraduate prerequisites could be done at these other locations and then the students could stay on their own campus and receive our already well developed and successful program via the Internet and teleconferencing with their clinical courses done in their communities. We currently have 31 on-campus students and 12 DE students. We are admitting 30 oncampus and 20 DE students in May of 2002. UNC Chapel Hill Department of Medical Allied Health Response Workforce Data Challenges Because of the diversity of professions included in the category of Allied Health, there is no single source of reliable workforce data for this group of health professionals. Rather, university program planners must rely on a combination of national workforce studies provided by the U.S. Bureau of Labor Statistics, the U.S. Health Resources Services Administration (HRSA), and the U.S. Government Accounting Office, direct communication with employers in North Carolina, and the results from a small number of discipline-specific work force studies conducted by the Cecil B. Sheps Center for Health Services Research at UNC Chapel Hill. Changing patterns of health care practice and reimbursement policies, combined with the aging of the general population, add to our difficulty in accurately anticipating the levels of supply and demand for various allied health professionals in North Carolina. Thus, our educational system needs both the capacity and the flexibility to adjust our program offerings in response to these fluctuating workforce scenarios. In response to these challenges, a group of employers and educators concerned about the allied health workforce in North Carolina collaborated with the AHEC to establish the Council for Allied Health in North Carolina (CAHNC) in 1988 as noted in Part I. From its inception, this Council has included strong representation from the UNC system, as well as the North Carolina Community College System, major North Carolina health care employers, and the professional associations of 27 allied health professions. For the past 14 years, this Council has operated with in-kind support from AHEC, UNC, and the N.C. Hospital Association. In 2001, AHEC received a 3-year grant from the Duke Foundation to support the activities of this Council, and specifically to fund workforce studies in specific allied health disciplines identified by Council representatives as being at high risk for current and future workforce shortages. 41

Acute and Critical Workforce Shortages At this writing, North Carolina employers are reporting critical workforce shortages in the following allied health professions: Radiologic Technology Imaging and Radiation Therapy Clinical Laboratory Science Medical Technology Cytotechnology Health Information Management. It should be noted that similar shortages were being reported 5 years ago in the fields of: Occupational Therapy, Physical Therapy, and Speech-Language Pathology. In response to those identified needs, the state of North Carolina allocated expansion funds that allowed the UNC system to hire additional faculty and thus increase the numbers of students who could be trained in these 3 fields. Two recently completed workforce studies, conducted by the Sheps Center in conjunction with the CAHNC, found that we now have an appropriate balance between supply and demand for professionals in both Physical Therapy (Council for Allied Health in North Carolina, 2000) and Speech-Language Pathology (Council for Allied Health in North Carolina, 2001). Chronic Allied Health Workforce Shortages Workforce data for North Carolina consistently reveal two types of chronic workforce shortage for allied health professionals across all disciplines: Shortages in Unserved and Underserved Communities: Unserved and Underserved communities are identified and reported by the HRSA annually. The most recent report identifies over 200 such communities in North Carolina, most of these clustered in regions and communities with low per capita income. Many of these communities are located in the eastern region of the state; and many are predominantly minority communities. Although the HRSA reports are based on numbers of primary care providers (M.D.s, P.A.s and Nurse Practitioners), our allied health workforce studies and employer reports indicate the same pattern of personnel shortages for the allied health professions. Shortage of Minority Practitioners: The population of North Carolina is currently reported to be approximately 74 percent majority (white/european descent) and 26 percent minority (African- American; Hispanic, Native-American; Asian). However, within the allied health professions in North Carolina, the percentages of minority practitioners generally range from less than 1 percent to 15 percent. Further, those fields reporting the largest proportions of minority practitioners are those requiring the least amount of post-secondary education and paying the lowest salaries. Recruitment and retention of minority students into Baccalaureate and graduate degree programs is a major challenge facing most of the UNC system Allied Health programs today. These programs tend to have very limited financial aid to offer qualified minority students; and are often competing with better endowed schools/ programs (e.g., Medicine, Law) that can offer minority students the promise of more lucrative careers, as well as more financial aid. 42

Anticipated Workforce Shortages Beyond the current acute and chronic shortages identified above, program directors in Allied Health programs in the UNC system are concerned about impending shortages that threaten to reach the critical stage within the coming decade. These anticipated shortages are directly related to the so-called graying of America, and the aging populations of patients, practitioners, and university faculty. With the aging of the general population, we are already beginning to see increased demand for allied health professionals essential to the diagnosis and treatment of many age-related disease processes (e.g., stroke, cancer, Alzheimer s Disease, bone fractures, respiratory diseases). At the same time, a large percentage of the allied health work force will reach retirement age over the next 10 years. Finally, the university and college faculty who prepare allied health practitioners are also beginning to retire, creating a need for Ph.D. programs in the allied health sciences to produce the faculty who will be needed to prepare future generations of practitioners. Beyond these demographic pressures, current trends in health care practice patterns and reimbursement policies are resulting in expanded scopes of practice for many allied health professions. In response to these expanded responsibilities, certification requirements are increasing which, in turn, means that university programs must increase the level and amount of professional training that we offer. These pressures have already resulted in the transition from B.S. to M.S. as the entry degree for Occupational Therapists; and from the M.S. to the Au.D. for Audiologists. At UNC Chapel Hill alone, we are already gearing up for three additional degree expansions in response to increasing scopes of practice for Physical Therapists (moving from an M.P.T. to a D.P.T. entry-level degree); Cytotechnologists (to shift from a post Baccalaureate Certificate to a Masters degree program); and Radiography (to add a new Physician Assistant level practitioner, which will require a post-baccalaureate Certificate or Masters degree). UNC System Response to Allied Health Workforce Shortages Current Activities As noted above, UNC responded to shortages in several therapy fields in the mid 90s, with the infusion of expansion dollars that allowed campuses offering programs in those fields to increase their student capacity. This response allowed UNC to address what was a critical workforce shortage without incurring the additional costs of starting up entire new programs or departments. Similarly, collaborative projects involving multiple UNC campuses, funded through UNC distance education grants, have allowed us to address short term, North Carolina personnel needs in the areas of Speech-Language Pathology and Rehabilitation Counseling. Finally, UNC s active participation in and support of the CAHNC allows us to monitor statewide allied health workforce issues, and to coordinate recruitment and retention activities among all the members, including employers, community colleges, private colleges, and the UNC system. The current critical shortages have come at a time of statewide budget cuts, making it difficult for the UNC system to respond to these needs. In fact, across the state, a number of public and 43

private post-secondary institutions are reported to be closing portions of their allied health programs because of the high costs of delivering this type of intensive, professional education. Program administrators are looking to other sources e.g., private employer groups and Federal agencies to fund stop-gap solutions. For example, the UNC Chapel Hill Radiologic Sciences program has entered into agreements with three regional hospitals (Duke, UNCH, and Alamance) to implement a new post-baccalaureate Certificate program that will produce an additional 20 radiographic technicians per year over the next 5 years. All of the costs associated with this program, including faculty salaries, will be paid by the 3 sponsoring hospitals. A grant to fund a similar certificate program for Clinical Laboratory Scientists has been proposed to the US Department of Health and Human Services. The chronic issues of workforce diversity and shortages in unserved/underserved areas have been the focus of collaborative efforts involving the UNC system, the AHEC system, and the CAHNC. One major focus of the Duke Foundation grant mentioned above will be to coordinate and strengthen our statewide efforts to recruit students from underrepresented minority groups into the allied health education programs offered by North Carolina s community colleges and comprehensive universities. The support of a School of Allied Health at ECU represents a major commitment by UNC to address the underserved communities in the eastern region of the state. Further, the AHEC Allied Health Coordinator works closely with the Department of Allied Health Sciences at UNC Chapel Hill to encourage and support allied health student clinical rotations in underserved communities throughout the state. UNC Responses to Allied Health Care Needs If additional funds were available to the UNC system allied health programs, such funds could support strategic initiatives designed to address the workforce issues discussed in this report. Areas of potential support would include: Targeted Financial Aid Programs: A system-wide set-aside of financial aid incentives would greatly enhance our efforts in recruiting students to allied health professions experiencing critical shortages, as well as recruiting underrepresented minority students into the higher degree level allied health professions. Flexible Program Expansion Funds: Multiple factors cause frequent changes in the relative supply and demand for professionals in the over 100 allied health professions. These include changes in Medicare/Medicaid funding levels for specific services and procedures, changes in state licensure laws and national certification standards, the development of new medical technologies, and the overall state of the economy. A system-wide fund might support 3- to 5-year grants to fund temporary program expansions so that more students could be enrolled in existing programs within the UNC system. Such funds would allow programs to hire additional, fixed-term faculty, and to pay the additional costs associated with a temporary increase in student enrollment (e.g., development of additional clinical sites, additional laboratory and teaching materials). Support for Coordinated Student Recruitment Program: The CAHNC is committed to the development of a system for coordinating the multiple student recruitment activities 44

conducted by AHEC, several large hospitals, and most individual colleges and universities in North Carolina. This effort will be supported with funds from a 3-year Duke Foundation grant. When that grant ends in December 2004, there will certainly be a need for some permanent source of funds to maintain the system developed through this grant. As the largest educational partner in the CAHNC, it would be very appropriate for the UNC system to contribute to the support of this ongoing activity. Support for Future Workforce Studies: The 3-year CAHNC grant mentioned above will also fund a finite number of allied health workforce studies, to be conducted by the Sheps Center. A subcommittee of the CAHNC is charged with the responsibility for selecting the specific professions to be studied. For the year 2002, the committee has prioritized two disciplines: Radiologic Sciences and Health Information Management. Again, there will be a need to secure permanent funding for future studies after the grant ends in December 2004. AHEC Planning Encompasses the Following: Continue to support and participate in the permanent establishment of the Council for Allied Health. A grant from The Duke Endowment to the AHEC Program will support the work of the Council for three years, but permanent funding will be needed for future years. Continue to support and participate in studies assessing the supply and distribution of allied health occupations in North Carolina. Develop new recruitment initiatives to increase interest in allied health careers, with special focus on underrepresented minority groups. Encourage university partners to design and offer special support programs, similar to the MED program at the UNC Chapel Hill School of Medicine, to recruit minority and financially disadvantaged students. AHEC would assist with recruitment of students and regional support. Administer a program of clinical site development grants modeled after the program that AHEC has administered in nursing for the past 12 years. These grants would aid the development of additional training sites to both maximize enrollments in allied health programs and expose students to practice in underserved areas and with underserved populations. Dentistry UNC has one school of dentistry, which is located at the University of North Carolina at Chapel Hill. Academic offerings are available in the professional academic program of Dentistry (D.D.S.) and in eleven graduate programs in dental clinical sciences. These specialized graduate programs comprise offerings at the master s and doctoral levels and in areas such as Oral Biology, Prosthodontics, Periodontology, Pediatric Dentistry, Orthodontics, Oral Maxillofacial Radiology and Surgery, Endodontics, and Dental Hygiene Education. Each year about 70 graduates earn professional degrees in Dentistry and about 25 earn degrees in the specialized clinical science programs. Enrollments have remained constant at the School of Dentistry with approximate enrollment of 300 students each fall in the professional program and 80 students in the specialized programs. Senate Bill 1005, Section 31.10. (d) requires the UNC Board of 45

Governors to study the feasibility of establishing a School of Dentistry at East Carolina University. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) DENTISTRY Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) 51.0401 Dentistry (D.D.S., D.M.D.) Fall Enrollment 297 297 304 70 51.0501 Dental Clinical Sciences/Graduate Dentistry (M.S., Ph.D.) Fall Enrollment 83 84 82 27 Total Dentistry 380 381 386 97 12 programs (10-M; 1-D; 1-P) UNC Chapel Hill School of Dentistry Response Currently the dentist-to-population ratio in North Carolina is 47 th from the top among the 50 states. The number of dentists per 100,000 people has in fact grown slightly from 38 in 1978 to 40 in 1998. The comparable 1998 U.S. figure is 58 dentists per 100,000, a ratio 45% higher than that in North Carolina. In North Carolina, the number of hygienists per 100,000 people has almost doubled between 1978 and 1998, and that rate grew faster in North Carolina than for the U.S. as a whole. A considerable proportion of the dental hygienists have left the workforce, however. The current physical facilities are one of the limiting factors to significantly expanding the class size of any of the programs. The lecture halls and preclinical teaching laboratories will not accommodate more than 79 students. In order to increase the DDS class size by 1/3, additional teaching facilities would need to be built. The patient care training could be addressed by using community-based clinics throughout North Carolina. For training additional hygienists, the dental school is currently developing a distance-learning program in conjunction with some of the community colleges. Increasing the number of dentists hours by producing more dentists may not be the most costeffective way to increase productivity and subsequently dental services. Increasing the hours of dentists and staff and utilization of expanded duty personnel are ways to increase productivity without an increase in the dentists. The current class sizes for the various educational programs at the School of Dentistry are: DDS 75-79, Dental Hygiene 36, and Dental Assisting 24. Current enrollment for these programs is 304 (four year program), 66 (two year program) and 21 (10 month program) respectively. All are expected to graduate at the end of their program. Each year approximately 80 percent of the DDS students, 98 percent of the dental hygiene students and 100 percent of the dental assisting students remain in North Carolina. One group that is frequently overlooked when discussing dental workforce issues is the dental laboratory technicians. Durham Technical Community College has the only formal training 46

program in North Carolina for dental laboratory technicians. The class size is 10 and 19 are currently enrolled (19 month program). The aging of the population creates an increased demand for fabrication of dental prostheses to replace teeth and related dental structures. Dental laboratory technicians, who fabricate these prostheses, are a vital part of the dental workforce and the adequacy of the number of technicians must be determined. Access to dental care is often a part of the discussion of the perceived dental workforce shortage. However, access to care is more related to the distribution of dentists than to the need for more dentists. The unfavorable dentist-to-population ratio, the disparity in dentist availability between metropolitan and non-metropolitan counties, attrition in dental hygiene workforce participation, and the large scale erosion in dental Medicaid funding in North Carolina are the central features of the dental care access issue. Dental Medicaid funding in North Carolina has been allowed to erode dramatically between 1979 and 1998. Dental Medicaid expenditures in 1979 constituted four percent of total Medicaid expenditures, but by 1998 the same ratio stood at near one percent, a decline of approximately 80 percent in relative Medicaid allocation for dental services. The School of Dentistry has made no reductions in funding of health workforce preparation programs other than those reductions required by the State to meet the current budget shortfall. A total of $1,179,779 in permanent and temporary reductions was made for this purpose in the current fiscal year. Summary: 1. Existing and future plans to address critical dental workforce training and shortage issues. (Significant changes will require adequate appropriations.) Continue to educate dental, dental hygiene, dental assisting and advanced education program students Continue to provide continuing education programs for practicing dentists and allied dental personnel Develop distance learning programs for training dental hygienists Development of a Geriatric Dentistry program Obstacles include continued budget reductions. 2. Additional plans that could be developed should additional resources be made available. Increase DDS class size by 33 percent Increase the number of pediatric dentistry residencies 3. Numbers of current and projected students enrolled and expected to complete dental related programs. DDS 304 (four years) Dental Hygiene 66 (2 years) Dental Assisting 21 (10 months) Pediatric Dentistry 10 (3 years) All of the above students are expected to complete their respective program. 47

4. Where students become employed upon completion of the various programs. 80 percent of the DDS students, 98 percent of the dental hygiene students, and 100 percent of the dental assisting students remain in North Carolina. The vast majority is in the private practice setting. AHEC Planning Encompasses the Following: Support programs to increase student awareness of needs of underserved populations. This would involve clinical site development in order to expand the opportunities for community based clinical experiences (in nursing homes or private offices for example) like the medical school model. In addition to financial resources, this would require State Board Action and a change in the current dental laws of North Carolina. Regional training initiatives, perhaps with a distance education component, designed to address the recruitment and retention of dental assistants and dental hygienists. These initiatives would involve the collaboration of the School of Dentistry, the AHEC Program, and the North Carolina Community College System and would have the potential to expand the capacity of community colleges to train (and graduate) dental assistants and dental hygienists. Support expanded dental residency programs with particular emphasis on pediatrics Medicine There are four medical schools in North Carolina, two of which, East Carolina University and the University of North Carolina at Chapel Hill, are constituents of the University of North Carolina. The number of students in the public medical schools each fall has remained relatively constant throughout the last decade with 928 students enrolled in Fall 2001. Each year the schools graduate approximately 225 new Doctors of Medicine. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) MEDICINE Health Professions and Related Sciences 51.1201 Medicine (M.D.) Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) ECU MD Medicine Fall Enrollment 300 299 291 71 UNC Chapel Hill MD Medicine Fall Enrollment 656 649 637 155 Total Medicine 956 948 928 226 2 programs (2-P) 48

East Carolina University Brody School of Medicine Response Present enrollment includes 75 students in year 1, 71 students in year 2, 72 students in year 3, and 71 students in year 4. There are an additional 7 students in the M.D./M.B.A. program. There are no definite plans to increase student enrollment. A workforce study is presently underway to determine which health care specialties are in the shortest supply, with the intent that resources would be dedicated to increasing programs to graduate students in that specialty. Should it be determined that the number of physicians graduated must be increased, impediments to implementing such an increase include the needs to increase classroom space, laboratory space, and faculty or faculty time devoted to teaching. Additionally, the medical school applicant pool appears to be decreasing; it would be difficult to increase the number of students and preserve high academic standards. The trend of students selecting careers in specialty rather than primary care medicine also has the potential to negatively impact ability to recruit students to this primary care-focused medical school. This will also likely have a negative impact on the school s ability to keep students practicing in primary care and rural settings in North Carolina after graduation and residency training. Additional resources might be used to renovate and expand classrooms to allow for an increase in class size, and to create model primary care teaching practices in rural settings in order to continue to keep students interested in the practice of medicine in such settings. Historically, approximately 1600 students have graduated from the program. Of these students, approximately 800 practice in North Carolina; 400 in eastern North Carolina and 200 in rural counties. Reductions in funding have already been addressed in the report from Vice Chancellor Richard Brown. In addition to these reductions, proposed federal cuts in funds from Title VII of the Public Health Service Act, which include $1.3 million to support training in rural areas for medical students, resident physicians, and faculty research, may jeopardize the school s ability to recruit and retain students for future clinical practice in the state. The ECU Brody School of Medicine has made no reductions in funding of health care workforce preparation programs other than those temporary and permanent reductions mandated by the current state budget shortfall. UNC Chapel Hill School of Medicine Response The School has no plans at this time either to increase or decrease the number of entering medical students from the long-existing first-year class size of 160. The more significant barriers to considering enrollment increases include: (1) on-campus facilities limitations, and (2) reasonable access to clinical teaching sites, materials, and patients resulting from shrinking clinical reimbursements to affiliated teaching sites. Another concern is lack of public policy consensus about whether enrollment growth is either needed or warranted on a national basis. (This issue is under active discussion and debate, with a preponderance of opinion at this time inclined toward the view that national needs call for enrollment growth in U.S. medical schools.) Recent years reductions in available state-appropriated funds to support the educational mission, along with uncertainties about future years funding situations, militates against any 49

consideration of growth in size of the M.D. degree program. Teaching faculty are even more pressured, as a byproduct of reduced state support, to pursue clinical practice and compete for research grants to generate the revenues needed to sustain current operations. The School s Department of Allied Health Sciences (e.g., laboratory technology, physical and occupational rehabilitation, speech and hearing, etc.) is currently limited in the size of its degree programs due in large measure to long-standing chronic inadequacies of physical space. Plans are well advanced for the complete renovation of a currently outmoded, obsolete School of Medicine research building, with funding from the Higher Education Facilities Bond Program of 2000. When this project is completed in 2005, there may be the opportunity for targeted program growth (i.e., increased enrollment) in the department. Any substantial growth, however, would still need to take into account faculty availability as well as need for expanded access to clinical teaching sites for students. The School of Medicine has not reduced funding for any health care workforce degree programs other than from mandated temporary and permanent reductions ($5,015,776 this fiscal year) due to the current budget shortfall. AHEC Planning Encompasses the Following: Continue to conduct specialty consultation clinics in various medical specialties in small towns that lack such services. Continue to support primary care residency training throughout the state Continue to collaborate with the Office of Research, Demonstrations, and Rural Health Development in the recruitment of residents to community practice sites and to support them once settled. Collaborate with other agencies to recruit physicians to underserved practice sites and to support them once settled. Increase the loan forgiveness program for settling in underserved areas. Utilize new educational technology to improve access and efficiency of CME. Provide opportunities for physicians to be exposed to new methods of patient care, disease management, evidence based medicine techniques, and advances in biotechnology & telemedicine. Identify and initiate strategies that improve cultural competency in the delivery of health care (such as the Spanish Language Initiative). There are currently resource needs for the primary care residency training programs. At a time of substantial reductions in federal funding to hospitals for medical education and related programs, state funds are essential to assure the continued capacity of the programs to meet the needs of the communities of the state. In addition to strengthening the capacity of all programs, funds are needed to address strategic initiatives that respond to critical needs for additional physicians include the need for more underrepresented groups entering the medical profession. 50

Mental Health In the mental health areas, the University offers programs in Clinical Psychology, Social Work, Genetic Counseling, Vocational Rehabilitation Counseling, Substance Abuse and Clinical Counseling, and Health Psychology. Also offered are programs in medical-related areas such as psychiatry, psychology, counseling, and others that have primary curricula in other areas. A number of UNC professional schools are engaged in health care personnel preparation to deal with various aspects of mental health. Mental health is one component of a range of health care areas (e.g., gerontology, minority health, etc.) that are addressed by schools of Allied Health, Medicine, Nursing, Pharmacy, and Public Health, which are covered in separate sections of this report. In addition, as noted in the AHEC comments below, schools of Social Work also have an important role to play in addressing mental health issues, and comments from these schools are provided below. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) MENTAL HEALTH Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) 42.2010 Clinical Psychology Fall Enrollment 75 78 87 26 44.0701 Social Work Fall Enrollment 1289 1255 1319 538 51.1306 Medical Genetics Fall Enrollment 0 7 17 0 51.1501 Alcohol/Drug Abuse Counseling Fall Enrollment 20 22 21 8 51.2310 Vocational Rehabilitation Counseling Fall Enrollment 40 47 49 20 Total Mental Health 1424 1409 1493 592 27 programs (12-B; 14-M; 1-D) East Carolina University School of Social Work and Criminal Justice Studies Response The problem of inadequate supplies of health care personnel are particularly severe in the rural areas and small cities of Eastern North Carolina. Mental health problems, and especially those relating to serious long-term conditions, substance abuse, and simultaneous involvement with mental health and other social welfare and criminal justice systems are critical. As a major regional institution, East Carolina University (ECU) and its School of Social Work and Criminal Justice Studies (SSWCJS) are committed to work toward healthier communities and individuals in the region, as well as throughout the state. This involves education in ways to develop citizens strengths, and to face directly the social and economic problems that spawn or exaggerate so many problems. The ECU SSWCJS is engaged in a number of specific measures, innovations, and initiatives toward this end. More are planned for the future as the School develops a new thrust to engage in community partnerships, particularly in child welfare and mental health. 51

Many of the current plans involve the preparation of personnel to operate North Carolina s evolving, reforming mental health care systems. There are no programs of social work or other professions in the state that do an adequate job of either training or continuing the education of persons to engage in the models of care, self-help, advocacy, and prevention that are required. Contemporary systems of mental health care, for example, are based on both social factors that are so crucial to recovery, and also to biological aspects of mental illness and its care. This void is being conceptualized as a niche for development at ECU SSWCHS. To this end, the school is forming partnerships to develop a new sort of opportunity for master s level social workers in eastern North Carolina. It has engaged in partnerships with existing and re-aligning mental health centers in AHEC Area L, and in the new center forming in Sampson, Duplin, Lenoir, and Wayne Counties to deliver off-campus MSW programs along the lines of its very successful distance education MSW programs in Elizabeth City and Wilmington. The school has also begun negotiations with Tidelands Mental Health Center staff to embark on a new teaching center concept. These initiatives are unified in offering the opportunity for graduate education in truly contemporary community health practice, unlike any currently available in the state. Not only the content, but also the sites, the technology, and the students will be oriented to forming the next generation of mental health organizational leadership and provision of care in the state. Because of the centrality of the mental health centers in forming these teaching centers, the school expects a large proportion of the students to be adult learners who study while employed in mental health and other systems. The school also intends to use nationally known consultants for its work with the people who will provide health care and those who will lead the systems in the near future. This work will make available new and beneficial collaborative opportunities for excellent relations with the AHEC units in the school s region. Continuing education activities will increasingly merge with primary professional education as everyone seeks a new and improved system. Students will learn in the same contexts in which they will practice, so that concerns about poverty, differences in access to and usability of services based on race and ethnicity or culture will be addressed from the start. Some of the biggest obstacles to these plans have to do with the limited amount of attention to systematic leadership development in the current system. Few are trained as innovators, for example, despite the enormous need for innovation at this time. A system of support for current employees, in effect a deliberate commitment to education for solving the major problems of the system while learning ways to innovate at the community and case levels in service provision would help enormously. In practical terms, a targeted stipend program coupled with support for faculty to teach and do continuing education, would go a great distance toward improving mental health care education and services. The ECU School of Social Work and Criminal Justice Studies has made no reductions in its workforce preparation programs other than those temporary and permanent reductions mandated by the current state budget shortfall. 52

UNC Chapel Hill School of Social Work Response The School of Social Work at the University of North Carolina at Chapel Hill offers graduate programs leading to the Masters of Social Work (MSW) and Ph.D. degrees. The mission of the School is to prepare students for careers in strengthening families and communities through public and nonprofit settings, to develop and test knowledge related to social work, and to provide leadership in addressing social problems (Adopted by the Faculty on May 21, 2000). In addition to the MSW and Ph.D., the school participates in interdisciplinary dual degree programs leading to students achieving MSW degrees and Law, Public Administration, and Public Health degrees. The School of Social Work, with its mission of teaching, research, and service, provides education for graduate level social workers, develops new knowledge in social intervention research that enables practitioners to provide best practices for their clients, and disseminates this knowledge and research to practitioners through publications, web based research to practice initiatives, and the development and implementation of professional social work training curricula. The school, which enrolls approximately 300 graduate (MSW and Ph.D.) students, provides instruction through its facilities on the campus of UNC Chapel Hill as well as maintaining three off-campus distance education sites for part time students in Asheville, Durham, and Fayetteville North Carolina. The school also provides distance education through the use of H.323 online web systems, NC-REN, and the N.C. Information Highway that allows the school to provide continuing education reaching the all areas of North Carolina. The School of Social Work has two curriculum concentrations Direct Practice and Management and Community Practice. Both of these curriculum areas provide education and training that are relevant to the mental health needs of North Carolina. The Management and Community Practice concentration provides students with the knowledge and skills necessary to focus on practice roles and skills in community development, planning, organizational change, and modeling community practice. The majority of the students at the School of Social Work are concentrating in Direct Practice, which provides students with the knowledge and skills needed to assess, practice, and evaluate social interventions with individuals, couples, families, groups within the ecological context in which they are embedded. Both of these areas are critical in the training of mental health practitioners in that mental health services are becoming more community based and will require organizational collaboration and organizational cultural change to maximize the effectiveness and efficiency of mental health service delivery at the local level. Students concentrating in these curriculum areas after graduation are employed in agencies across North Carolina including the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the Department of Social Services, the Developmental Evaluation Centers, day treatment facilities, faith-based organizations, juvenile justice, law enforcement, corrections, group homes, nursing homes and long-term care faculties, day care, vocational rehabilitation, state psychiatric facilities, mental retardation centers, alcohol and drug rehabilitation centers, hospitals, public health centers, rehabilitation facilities, substance abuse 53

inpatient and outpatient programs, inpatient psychiatric units, schools, prisons, and private practice. The School of Social Work seeks to recruit ethic minority and rural populations to increase the diversity of the MSW workforce. Further, through the N.C. Child Welfare Education Collaborative, the School attracts and trains practitioners and students interested in accessing the skills and expertise necessary for professional practice in the State s child welfare system. In addition to the on-campus and distance education sites, the School provides certification programs in the areas of treatment for alcohol, tobacco, and other drugs (ATOD), services to aging populations, and non-profit leadership. We also work with AHEC and provide continuing education for social workers throughout North Carolina. These training areas have included family and domestic violence, disaster response, closing the achievement gap, interventions with at-risk youth and their families to name but a few. The School further provides training and technical assistance numerous state agencies including the State Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the Division of Social Services, and the Division on Aging. Through state contracts and grants, the School of Social Work develops training curricula, implements this training, and publishes highly relevant practice newsletters for social work clinicians. With foundation and federal support, faculty and staff develop assessment tools relevant for evidence-based practice for children, adolescents, families, and communities. Examples of these efforts include the Adolescence Parenting Evaluation, The School Success Profile, Safe Start, and Making Choices. Given the shortages of trained MSW practitioners, the School of Social Work is dedicated to providing highly skilled Masters-level social workers who can meet the considerable demands of the changing landscape of mental health needs, broadly defined, in North Carolina. Current professionals must be skilled in the assessment, case management, and treatment of individuals and families within their contexts of relationships, school, work, community, and health. This is important for individuals whether they and their families are dealing with severe and persistent mental illness, substance abuse, physical abuse and trauma, or coping with depression, physical illness, death of family members, or the aftermath or Hurricane Floyd. This requires high order skills to respond effectively to complex problems and issues. These skills must be provided to a sufficient and adequate number of workers in North Carolina both through the full and part-time programs and also provide for the maintenance and upgrading of knowledge and skills via continuing education as operated by the School and AHEC. These goals are also accomplished through collaboration with State agencies to build, deliver and evaluate effective and efficient training curricula. As the skills necessary for mental health practice change, the School will alter its curricula to meet these changing demands. For example, recently the School combined fields of practice to allow students to see how physical and mental health are connected. This understanding allows social workers and health care personnel to work in greater accord and understanding. The School of Social Work continues to work hard to attract the most qualified and diverse students who are interested in working in public and non-profit settings that serve the most critical mental health populations in need in North Carolina. As the North Carolina mental health delivery system and subsequently the workforce is reorganized, the School of Social Work, 54

through teaching, research, and service, will continue to collaborate with the State to meet the varying planning, prevention, assessment, intervention, evaluation, and training needs of mental health practitioners. The ability to maintain this standard is, as always, dependent on expertise, capacity, and resource availability. The UNC Chapel Hill School of Social Work has made no funding reductions in its workforce preparation programs other than those temporary and permanent reductions mandated by the current state budget shortfall. AHEC Planning Encompasses the Following: Continue to support the off-campus rotations of medical students from the four medical schools for portions of their training in psychiatry. Continue to support the rotation of psychiatry residents from the four medical schools to community mental health facilities in North Carolina. Continue to support the efforts of ECU and UNC Chapel Hill Schools of Social Work to bring their MSW programs to off-campus locations. Continue to support the education of practicing mental health professionals through the provision of continuing education programs, technical assistance, and library and information resources. AHECs will collaborate with the N.C. Division of Mental Health/DD/SAS, with local mental health management entities, and with mental health practitioners to assess needs and develop new programs. AHECs will also assist the Division of MH/DD/SAS with statewide training initiatives such as case management and crisis intervention. Continue to enhance interdisciplinary training opportunities, support the rotation of family practice residents to community mental health centers, and promote strong behavioral medicine curricula in family practice residency training programs. Continue to promote the recruitment of racial and ethnic minority students into mental health professions. Continue to offer preparation for substance abuse practitioners working with Spanish speaking clients. Develop statewide training programs that utilize best practice models in high priority service areas, such as child and older adult disorders, substance abuse, dual diagnosis, schizophrenia, developmental disabilities, personality disorders, depression, assessment protocols, and cultural competency. Deliver a larger number of smaller, on-site continuing education programs and use technology such as videoconferencing and Internet-based courses to increase educational access for practitioners. As reorganization proceeds in state mental health system, assist with competency-based training aligned to new mental health care standards such as case management and protective intervention. AHEC Mental Health faculty has been reduced in overall numbers across the state due to budget cuts. Further reductions would seriously hamper outreach programs and activities. Financing of 55

many statewide training programs has historically been a partnership between the Division of Mental Health and the AHECs. Budget cuts in the state mental health system have already delayed or cancelled the offering of critical programs. Additionally, because funding from the Division of Mental Health had underwritten the cost of training, higher registration fees must be charged to participants who are also facing budget reductions at an agency level and may be unable to access funds to attend training. The prevalence of patients in primary care settings who have mental illnesses mandates the need for better linkages between primary and mental health care for adults and children. Additional AHEC programming and technical assistance are needed to reach these providers with training on mental health topics. Similarly, the prevalence of mental health issues and diagnoses among school aged children and adolescents indicates that programs are needed by school nurses and school counselors on mental health topics. There is a growing recognition of the need for both prevention and intervention training of mental health professionals on the disaster related (bioterrorism) mental health and substance abuse needs of both responders and victims/survivors. The Division of Mental Health/DD/SAS has asked for AHECs assistance in offering statewide training programs related to bioterrorism and mental health responses. Nursing The University of North Carolina has 10 Bachelor of Science in Nursing programs located at East Carolina University, North Carolina A&T State University, North Carolina Central University, UNC Charlotte, UNC Chapel Hill, UNC Greensboro, UNC Wilmington, Western Carolina University, Winston-Salem State University and a joint BSN program offered by Fayetteville State University and UNC Pembroke. Master s level education is offered at ECU, UNCC, UNC Chapel Hill, UNCG, UNCW, and WCU. These programs prepare mid-level primary care practitioners, nurse educators, nurse administrators and nurse anesthetists. UNC Chapel Hill has offered a doctoral program in nursing for 10 years and the UNC Board of Governors has authorized East Carolina to establish a new Ph.D. in Nursing program that will begin in Fall 2002. Both programs are needed to prepare nursing researchers, administrators, and faculty for BSN and MSN programs. Winston-Salem State University has planned a new Master s of Science in Nursing to prepare family nurse practitioners for the local area as well as the northwestern part of the state where the university has offered RN to BSN education for several years in Boone and Wilkesboro, North Carolina. With the assistance of AHEC, UNC nursing schools and departments currently offer RN to BSN distance learning programs at sites throughout the state and 224 students were enrolled in these off-campus programs in Fall 2001. Some nursing courses are also offered via the Internet and through interactive video using the N.C. Information Highway. Collaborative efforts and exciting new e-learning strategies are discussed in response to the questions below. Over the past ten years, the UNC nursing programs have been responsive to the needs of the state by expanding offerings and increasing capacity as much as possible in programs that have clinical requirements and mandated faculty/student ratios for licensure approval and 56

accreditation. Since 1990, baccalaureate enrollment has increased from 1,476 students to 2,055 students in Fall 2001; master s enrollment has increased from 475 students to 736 students and, doctoral enrollment has increased from 22 to 50 students. The combined nursing enrollment for all UNC programs for Fall 2001 was 2,841 students. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) NURSING Total Fall Year Enrollments 99-00 00-01 01-02 Total (2000-01) Baccalaureate 51.1601 Nursing Fall Enrollment 2231 2109 2055 1017 Master's 51.1605 Nursing, Family Practice Fall Enrollment 58 57 66 12 51.1608 Nursing Science Fall Enrollment 290 307 238 107 51.1611 Nursing, Public Health Fall Enrollment 1 1 1 1 51.1699 Nursing, Other Fall Enrollment 392 408 431 133 Doctoral 51.1608 Nursing Science Fall Enrollment 39 42 50 2 Total Nursing 3011 2924 2841 1272 19 programs (10-B; 7-M; 2-D) Combined Responses from the UNC Schools of Nursing The educational system for nurses is only one component of the supply and demand issue for North Carolina. Strategies to increase the number of nursing graduates should be implemented along with proactive efforts by employers, including competitive compensation and career development strategies, to retain nurses in practice. Realizing this, UNC proposes several ways to address the current and projected shortage. The Need for Nursing Faculty to Sustain and Expand Nursing Programs: Increase the number and availability of nursing faculty positions so that UNC programs can increase the number of students in pre-licensure programs that produce new nurses. North Carolina is facing a critical shortage of nursing faculty. The UNC nursing programs must produce nursing faculty for both UNC and the 45 North Carolina Community College System nursing programs. These programs cannot increase enrollment without additional nursing faculty. For example, UNC Greensboro offers an RN to BSN program in Hickory that admits students every other year. For the Fall 2002 class, they received 290 applications for 30 enrollment slots and they have developed a waiting list of eligible students. In order to expand enrollment at this site, UNCG needs additional faculty. Faculty for the UNC nursing programs must be prepared at the master s level and doctoral level. The UNC Board of Governors authorized a new Ph.D. program at East Carolina University that will start in Fall 2002 and that will help train additional university 57

faculty. Funds are needed to help UNC faculty progress through graduate study in a timely manner. At Western Carolina University, five of the 14 faculty members are teaching full-time while also enrolled part-time in doctoral programs. WCU is the only university in that region of the state that can prepare community college faculty. The UNC Office of the President will work with UNCG and WCU and other UNC institutions to expand master s programs that prepare nursing educators. Addressing the nursing faculty shortage also means expanding capacity in those programs that prepare MSN graduates for clinical nursing faculty positions. Funds to Expand the Nurse Scholars Program for RNs, BSN, and MSN Students: Over the last two years, the Nurse Scholars Commission received an annual average of 1,052 eligible applications per year and funded about 36% of them. With additional funds, the program could expand the program to include up to 50 additional slots (25 RN/MSNs and 25 part-time RN/BSNs). This program helps support high achieving nursing students for study in the North Carolina Community College System, private institutions and UNC nursing programs. Although tuition and fees have increased, stipends that are available for students have not increased in 10 years. State-Supported Summer School: Explore creative educational options such as state-supported summer school to facilitate accelerated degree completion. In order to hire nursing faculty for summer school, UNC nursing programs must be able to offer salaries that are competitive with those offered by health care employers. Competitive Faculty Salaries: Examine faculty salaries to make sure they are competitive with the health care market place and private sector. It is becoming increasingly difficult to recruit and retain faculty who can prepare students in specialty areas. Providing New Educational Opportunities: Explore innovative partnerships to support the preparation of nurses for the state. Review the funding mechanisms that will support the education of nursing students. Support graduate students to recruit and retain more nursing faculty, including scholarships, etc. Improve student advisement to increase retention and promote entry into graduate programs. Provide more opportunities for continuing education to facilitate improved care through skill building, retooling, retention and reduction of medical errors. Preceptor Development: Provide targeted monies that release expert nurses to a level of patient care and type of work schedule that allow them to fulfill a preceptor role so that hospitals have nursing FTE s to help in the education of nursing students and new graduates, thereby increasing the number of students they can accommodate. Need for Nursing and Workforce Data: Promote a consistent data collection system and make sure data on the nursing workforce are disseminated in a timely manner to appropriate agencies and administrators. Retention in Nursing: Encourage hospital administrators to examine their environment to address staff discord regarding the delivery of patient care; design ongoing educational mobility and staff development to address technological competence. Examine ways that nurses can 58

practice in an independent role when educationally prepared to do so. Explore shared governance modes such as the one used in St. Joseph Hospital in Atlanta and/or consider Magnet Hospital Study factors. Examine the work setting to identify the barriers and facilitators to retain nurses who give direct care; consider expanding the NCNC renewal/mentor/reward program. Explore ways that nurses can become more involved in local health policies committees. Provide targeted monies for residency programs in the state s academic medical centers and large community hospitals to stop the early attrition of new graduates from nursing by safely nurturing and guiding new graduates to a level of competence in acute and critical care before they are expected to take on the patient load of experienced nurses. Educational Mobility: Reexamine the community college level of training for health professionals to potentially create a more generic entry for patient care technical support that does not lock a graduate into (or out of) the variety of positions at the assistance level (surgery tech, radiology tech, ADN, paramedic, etc,); create paths to a variety of college/university health careers from that beginning level (BSN, MSN, PharmD, etc.). Diversify Nursing Workforce: Support recruitment strategies to increase the number of men, ethnic minorities, Spanish speaking students and other under-represented populations. Provide opportunities for young people from disadvantaged backgrounds to graduate from a baccalaureate program. Develop a program to enlist elementary, middle school, and high school students in nursing preparatory activities. Students will be assisted to: strengthen their mathematics, language arts, science, and computer skills; improve test-taking skills; engage in pre-cepted experiences with professional nurses; and participate in enrichment activities in the community. Promote increased use of accelerated delivery modes. This will offer greater access to more students, especially those in rural North Carolina. Differential Compensation: Hospital administrators should establish a salary scale and compensation package to reimburse nurses that is tied to educational preparation and role responsibility. Educational Portal for Nursing Students: Funds are needed to develop a portal that can be used by nursing students throughout the state to support educational mobility, career mobility, and academic advisement. NCLEX-RN Preparation: Establish funds to strengthen the preparation of at-risk students for the licensure exam. Best-Practices Models: Market best practices models of health care employers that have been successful in recruiting and retaining nurses in practice. The educational system is taking steps to assist in the development of an adequate supply of appropriately trained nurses and health personnel. Among them are the following: UNC and NCCCS Articulation: For the past ten years, the University of North Carolina, AHEC, and the North Carolina Community College System have worked to support the articulation of nursing programs from the community colleges to the universities through RN to BSN programs. 59

During Fall 2001, UNC enrolled 545 RN transfer students at the junior and senior level. The 10 UNC nursing programs enrolled 321 RNs on campus, and they enrolled 224 RNs at 9 off-campus sites. The North Carolina Center for Nursing has received a grant from the Helene Fuld Trust to form a Statewide Nursing Articulation Steering Committee. This committee is developing an articulation model that can be used by public and private universities throughout the state. The Bachelor of Science in Nursing degree strengthens the preparation of professional Registered Nurses in both nursing and important arts and sciences disciplines. For example, graduates of the state-supported joint RN to BSN program at FSU and UNCP are able to remain employed in the same health care agency but assume more responsibility for patient care. The BSN is also the preparation for entering graduate programs that produce nurse practitioners and nursing faculty. The UNC Office of the President and AHEC support efforts to develop RN to BSN programs online. This includes a collaborative model for seamless articulation being developed by UNCC and UNCW. ECU and UNCG have developed MSN courses on-line. Accelerated BSN and MSN Educational Programs: Winston-Salem State University has developed several creative tracks to develop new nurses, including a highly successful track that trains Emergency Medical Technicians as Registered Nurses who also obtain the Bachelor of Science in Nursing degree. UNC Charlotte has developed two RN-BSN options to significantly enhance access of N.C. nurses to BSN education. Option 1 is an on-campus program that permits practicing RNs with an associate degree to complete their BSN in one calendar year (fall-spring-summer). UNC Charlotte s Option 2 for the RN-BSN program is a web-based option. This option allows practicing RN s with an associate degree to complete their BSN through on-line courses on the Internet. Several UNC institutions offer RN to MSN study options, including ECU, UNCC, UNC Chapel Hill, and UNCW. Partnerships: Develop more partnerships involving education and health agencies. The UNC Chapel Hill School of Nursing and UNC Health Systems have formed a partnership to offer an accelerated BSN for second-degree students. ECU has recently negotiated a partnership with Pitt County Memorial Hospital (PCMH) to increase enrollment in the pre-licensure BSN program. Under this arrangement, PCMH provides faculty support for additional clinical sections of nursing courses. ECU increased the number of admissions by 10 students in each class. That is from 80-90 students. Students are admitted each semester, thus the program has increase capacity to 180 each year, instead of 160. Future plans include increasing admissions to 100 students in each class. To assure an adequate applicant pool for this admission model, the university has developed a number of marketing strategies including TV and radio ads, revised brochures, and additional recruitment visits to high schools and community colleges. All UNC programs need additional funds for recruitment. Another strategy is to identify academic majors who could consider nursing as a second degree before graduation. All UNC nursing programs provide off-campus BSN education for registered nurses. This approach has significantly increased the number of BSN-prepared nurses in the state. Western North Carolina Network: The nursing department at Western Carolina University is an active participant in the Western North Carolina Network that is organized to address health professional shortages in the region. AHEC Staff, educators, and employers have developed a plan to ensure that the supply of nurses and allied health professionals meets the demand for professionals needed by health care facilities. Plans include the development of a supply and 60

demand forecasting model, the development of partnerships to help recruit faculty and improve salaries, and an assessment of the need for additional preceptor and clinical sites. WCU is also considering a nursing educator concentration in the MSN program. Public and Private Collaborative Efforts: East Carolina University and Duke University received a Partners in Training Grant from the Robert Wood Johnson Foundation to train Nurse Practitioners, Nurse Midwives and Physician Assistants through a interdisciplinary programs. This approach enables students from medically under-served counties in North Carolina to take classes and continue to work part-time. They will complete the last year of their training as full-time students in clinical settings. The goal of the program is to train students in their local communities so that they will stay in their communities after graduation. This partnership includes Physician Assistant students and Nurse Midwifery students from ECU and Nurse Practitioners students from both Duke and ECU. Recruiting in Non-traditional Arenas: WSSU recruits graduates of universities and colleges that do not have nursing pre-licensure nursing programs such as North Carolina State, St. Augustine, Knoxville College, and Fayetteville State University. WSSU has also developed articulation agreements with several Communities Colleges. The nursing department is also working with the continuing education department to recruit adult learners. Working with the Local Communities to Pool Resources: WSSU along with the Winston-Salem Chamber of Commerce and local health care agencies has implemented a taskforce to address the workforce issues for shortages in all health care provider classifications. Currently the group is collecting local data, developing promotional materials for local media promotions, and presenting job fairs and working with displaced workers. The university is also recruiting for an Endowed Research Chair, which will focus on research in recruiting and retaining both nursing students and registered nurses in the local and state communities. This is a collaborative effort between WSSU and Forsyth Medical Center. Partnerships to Increase Clinical Faculty: UNC Charlotte is exploring innovative partnerships with area health institutions. For example, the University is currently working on an agreement for a partnership with one hospital system that may result in the hospital contributing funding support for clinical faculty. If this agreement is developed, UNCC could admit 10 additional BSN students. Collaboration among UNC Nursing Programs: UNC Charlotte has engaged in collaboration with UNCW to jointly develop courses in the RN BSN program and the two universities now have been funded from E-Learning funds to develop all the major courses which may be taken in either institution and transferred to the other. ECU and UNC Chapel Hill nursing programs have expressed their interest in joining this collaboration to expand to four UNC schools of nursing working collaboratively in the next phase of distance education planning. Federal Funding to Support Articulation: A federal program exists at National Institute of Health to provide financial assistance for collaborative RN to BSN programs. Together with state funding, such an initiative could be sustained in North Carolina. 61

Collaboration with Health Care Agencies to Increase the Number of Clinicians Entering the Workforce: Future plans for WSSU include collaborations with Wake Forest University Baptist Medical Center to establish an accelerated program to begin Spring 2003. The program is designed to be completed within 13 months. The university has submitted a proposal to implement a nurse Practitioner program. The graduates will help alleviate the shortages in Community based facilities and acute care facilities. Annually, ECU nursing faculty participates in the summer ventures project in conjunction with Eastern AHEC. This project brings high school students to the campus for a week of education about health careers. The Board of Governors has authorized East Carolina University to start a new doctoral program in nursing. Although UNC employees a large number of master s prepared clinical faculty, the University needs to assess the need for doctoral prepared faculty over the next five years. As soon as UNC and North Carolina entered SREB s Academic Common Market, the University contacted nursing allied health and nursing deans to let them know that their faculty could enroll in graduate programs included distance-learning programs that are not offered by UNC institutions and receive in-state tuition. WSSU has started to increase the number of graduates who can enter the workforce without the need for extensive orientation, such as paramedics, LPNs, and individuals classified as second degree. WSSU is offering several entry/exit points and provides the possibility for more students to complete the program without exceeding capacity issues as prescribed by the board of nursing, yet produces graduates graduate more than the capacity. WSSU is also utilizing the summer sessions to advance juniors so that they may graduate in December. Funding During this period of a state budgetary crisis, it is difficult to mount new initiatives and sometimes difficult to maintain recent gains in the nursing area when resources are being reduced. Nonetheless new programs are being implemented and efforts are being made to maintain and expand access to the health care educational programs. Employment of UNC Nursing Graduates Approximately 97% of the graduates of the nursing program at Winston-Salem State University are employed in nursing in North Carolina. High employment rates in North Carolina health care are also recorded for the off-campus nursing sites offered by UNC and AHEC. Graduates from ECU's nursing program are largely employed in eastern North Carolina. Over the last 5 years more than 50% of each of the graduating classes have had their first job in eastern NC. An additional 30% of graduates have their first job elsewhere in NC. More than 90% of ECU s new graduates have the first job in hospitals and predominantly as staff nurses. An example, provided by UNC Charlotte shows the distribution of employment of the graduates of the College of Nursing and Health Professions: Hospitals, 27%; Medical Centers and Private Practices, 26%; Other Health-related Agencies, 20%; Health Departments, 10%; Graduate School or Public Schools, 10%; Nursing Homes, 6%; Business, 1%. North Carolina AHEC Program 62

AHEC nursing faculty recognize that solutions to educational and workforce issues in nursing are complex. Continued efforts and innovative, coordinated, and comprehensive responses utilizing new educational strategies, programs, and services will be required. Although an overall shortage of registered nurses may not take place until 2010, that shortage is almost inevitable, and now is the time that employers and nursing leaders should begin working together to plan how best to use increasingly scarce RNs to deliver patient care in the future. The North Carolina AHECs will continue to be well suited to collaborate with the North Carolina Center for Nursing, health care agencies, educational institutions and the nursing profession to assess needs and to respond to nursing issues throughout the 2001-2005 period. Taking into account current access to health care across North Carolina, some regions and subpopulations do not have adequate access. The education sectors are addressing access through a wide range of health professions programs and through extending health care services to underserved regions and groups. AHEC will continue to support the education and training activities of nursing students on rotation in the AHEC regions. Students on rotation away from campus continue to need technology support for computer-based curricula. AHEC will also continue to support the education and training needs of practicing nurses through the provision of allied health continuing education programs, technical assistance, and the availability of library and information services throughout the state. AHEC Planning Encompasses the Following: Continue to implement the recommendations and mandate of the 1989 and 1991 Legislative Commission on Nursing. Support preceptor development in the creation of new clinical training sites for nursing programs. Support efforts designed to recruit minority and non-traditional students into nursing. Provide educational opportunities for nurses in administrative positions. Continue to promote innovative off-campus baccalaureate and master's opportunities for registered nurses and to encourage opportunities for off-campus graduate nursing education for nurses in specialized settings, in advanced nursing practice, and for faculty in community college/technical institute programs. Provide continuing education, technical assistance, and consultation to nurses at all levels to develop health promotion expertise and clinical skills, acute and rehabilitative, necessary for practice in community, inpatient, and ambulatory settings. Expand management and supervision courses for nursing leadership to improve practice environment and retention. In order to provide statewide systematic nursing management education, the AHEC Program has proposed developing a Nursing Management Institute that would develop an Internet-based set of resources and a curriculum combined with selfassessment and regional mentoring and follow-up. 63

Establish an AHEC competitive grants program (like the clinical site development grants) to for the employers of nurses and other health personnel to develop innovative pilot programs and projects (like magnet hospital programs) to improve the workplace setting. Could be directed to pilot projects to improvement nursing support services, productivity efforts (that could include computerization efforts), integrated pay career advancement and education plans, etc.) There are critical shortages of nurses, nursing assistants, and nursing aides in long term care agencies for the elderly. There is a need for a comprehensive recruitment, retention, and career mobility training effort in long term care. Some AHEC components of a statewide comprehensive plan could include: Course development and implementation in team building, motivation, supervision delegation, leadership, and management for directors, supervisors and aides (including curriculum development, CDs/video materials, training trainers, workshops etc. Career ladder development /training for CNAs (such as the Win A Step Up program being piloted by the Division of Facility Services of the N.C. Department of Health and Human Services). Strengthen career development and mobility programs, including distance degree and nurse refresher courses. Expand clinical site development for specialties experiencing shortages. Intensify recruitment efforts to increase enrollments, especially among minority students. Develop active alliances with historical black educational institutions and create a graduate Nursing Education Enrichment Program to assist in recruiting and preparing under represented minorities for advanced practice. North Carolina Center for Nursing The Center for Nursing works closely with multiple partners to address issues in nursing and the complex issues involved in maintaining an adequate nursing workforce. It has developed a number of statewide initiatives to address issues of recruitment and retention ranging from radio and TV public service announcements to materials to acquaint middle school students with the opportunities for a career in nursing. The Center has a number of proposals to address the nursing shortage: 1. Increase funding for nursing education programs in community colleges and baccalaureate and higher degree programs, in order to accommodate more students. Faculty salaries need to be enhanced and we need more positions. Resources are needed for pilot testing of, graduate nurse internships and more fast-tracks for preparing second degree students for nursing careers. There is a critical need to increase the number of Master's-prepared nurses qualified to teach. 64

2. Improve distance education (infrastructure, AHEC funding, videoconferencing, faculty release time for development of web-based instruction). 3. Enhance articulation among the various levels of nursing programs in the state. One vision is to offer nurse aid training in every high school, followed by a seamless system for nursing education that allows qualified students to progress, unhampered by unnecessary barriers. 4. Provide funding to increase the capacity of the North Carolina Community College System to train nurse aids, with more standardized content and testing. 5. Enhance Nurse Scholars funding: Explore the development of a nurse fellows program, similar to the teaching fellows program Increase the amount of the awards in keeping with tuition increases Consider awards to spring semester enrollees Increase awards for part-time RN-BSN students Include RN-MSN students for awards Although North Carolina appears to be faring better than the majority of states, in terms of its nursing workforce, we are very concerned about an evolving nursing shortage that is actually global in nature. Even within the context of current budgetary constraints, we can ill-afford not to address long-range nurse workforce solutions. Pharmacy The entry-level program for practicing pharmacists is the Pharm.D. professional program that is offered through the School of Pharmacy at the University of North Carolina at Chapel Hill. Other offerings include the research-based graduate studies in the Pharmaceutical Sciences at UNC Chapel Hill and a doctoral program in Pharmacology at East Carolina University. About 100 new pharmacists enter the profession earning a Pharm.D. each year through the UNC program, and about 45 other professionals upgrade their credentials with this degree for a total of approximately 145 Pharm.D. degrees conferred each year. Ten years ago, most pharmacists were entering the profession completing solely the baccalaureate entry-level pharmacy program. However, with the change of entry-level requirements to the Pharm.D., as expected, there has been a dramatic change in the number of enrollments and degrees conferred at the professional level. In 1991-92, there were 491 students enrolled in the baccalaureate pharmacy programs and 148 degrees were conferred in this program. At the Pharm.D. level in 1991-92, only 30 students were enrolled and 14 degrees conferred. The total 1991-92 enrollment in all of the pharmaceutical sciences including the professional pharmacy areas was 585 students, and 170 degrees were conferred at all levels. The picture shifted in 2000-01 with the new entry-level requirements of the Pharm.D. The baccalaureate programs become obsolete and there was no enrollment at this level or any degrees conferred. However, the number of students enrolled in the Pharm.D. program has risen from 30 65

students in 1991-92 to 464 in Fall 2000. During the 2000-01 year, 145 Pharm.D. degrees were conferred. The total number of students in all of the pharmaceutical sciences including the professional pharmacy areas in 2000-2001 was 525 students, and 156 degrees were conferred at all levels, a decline from the ten-year comparison of professionals entering the field. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) PHARMACY Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) 51.2001 Pharmacy (B. Pharm., Pharm.D.) Fall Enrollment 533 534 559 145 51.2003 Medical Pharmacology and Pharmaceutical Sciences Fall Enrollment 67 70 76 12 Total Pharmacy 600 604 635 157 4 programs (1-M; 2-D; 1-P) Senate Bill 1005, Section 31.10. required the UNC Board of Governors to study the feasibility of establishing a School of Pharmacy at Elizabeth City State University. The feasibility study, conducted by three deans of pharmacy, provided three options a stand-alone program at ECSU or cooperative programs with either ECU or UNC Chapel Hill. The board supported the third option (cooperative program with UNC Chapel Hill) as the most cost-effective program and one that could produce new PharmD student earlier than the other options. UNC Chapel Hill School of Pharmacy Response There can be little doubt that a serious shortage of pharmacy manpower exists in North Carolina, and the problem is likely to continue for the foreseeable future. It is important to note this shortage is not unique to North Carolina, but is repeated in most (if not all) states`. It should also be noted that the shortage does not derive from a reduction in enrollment or graduation rates, but rather from a net increase in demand for pharmacists services. The three main forces driving this change are: (1) an aging population that requires more, and more complex pharmacotherapy, as a function of age, (2) a pharmacologic revolution producing new drugs that are both more effective, and effective in previously untreatable conditions, and (3) a health care reimbursement system that strongly favors non-institutional (i.e., home-based) care, and thereby places increased reliance on drug therapy. While technological and regulatory approaches are essential components of a solution, additional pharmacists are absolutely necessary. It should be noted that the PharmD is not a 6-year degree. The PharmD is a four-year curriculum, to which a student is admitted after completing pre-pharmacy requirements. Just as in medicine or dentistry, the pre-pharmacy period is indeterminate in length. (The average prepharmacy matriculation of Carolina pharmacy students is approximately 3.9 years.) It is incorrect to describe the conversion of pharmacy education from a five year baccalaureate degree to a six year doctoral degree. The conversion did not simply require programs to add one or two years, but to redesign an entire curriculum around a four-year doctoral model. It is 66

important to avoid any suggestion that the PharmD curriculum is an expansion of the baccalaureate curriculum. Rather, it represents a complete re-engineering of the pharmacy education, consistent with the first sentence of the section on pharmacy, which described pharmacy as uniquely among the health professions developing a rational planning model for meeting societal needs. The additional comments on AHEC, as noted in the draft, are important. It is essential to note that three resources are relatively fixed: (1) the number of available faculty, (2) the number of available students, and (3) the number of available training sites. These have been stretched to the limit in North Carolina, and any additional enrollment (through new programs or expanded enrollment), will require resources and effort to expand these resources. To a disproportionate extent, this falls within the mission of AHEC. Finally, the first and most cost-effective strategy for producing additional pharmacy manpower is to fully utilize existing resources. The UNC School of Pharmacy is recognized as one of the premier programs in the U.S., and with the completion of Kerr Hall (scheduled for completion in August, 2002) this program will have the capacity to increase enrollment by 20%. The cost/student of expanding enrollment at Chapel Hill will be much lower than any option available to the UNC system. The School of Pharmacy expects to expand enrollment immediately if marginal costs can be covered. The UNC Chapel Hill School of Pharmacy has made no funding reductions in its workforce preparation programs other than those temporary and permanent reductions ($518,623 this fiscal year) mandated by the current state budget shortfall. AHEC Planning Encompasses the Following: Develop additional clinical sites to support projected student growth or additional pharmacy schools. Expand certification programs in disease management (diabetes, asthma, hypertension, etc.) to prepare pharmacists for expanded clinical roles such as the clinical pharmacist practitioner. Support development and expansion of quality pharmacy technician programs. In addition support the mandatory registration, certification and/or licensure of technicians in combination with the development of accessible educational programs to prepare pharmacy technicians to take the national certification examination. Expand community-based pharmacy residencies for primary care training and such specialty residencies as geriatric pharmacotherapy. Public Health The public health programs in the University of North Carolina include the disciplines of public health practice and leadership, public health promotion and education, health behavior and health education, community health education, general public health, and maternal and child health. 67

Currently there are five programs at the baccalaureate level, eight at the master s level, and four programs at the doctoral level. Each year more than 225 students complete degree programs in the public health areas, and in Fall 2001, there were 580 upper division undergraduates and graduate students majoring in these programs. Upper division undergraduates compose 31% of the total public health enrollment; 56% at the master's level, and 12.9% at the doctoral level. UNC HEALTH CARE PROGRAMS (Enrollments and by Academic Program) PUBLIC HEALTH Total Fall Year Total Enrollments 99-00 00-01 01-02 (2000-01) 51.2201 Public Health, General Fall Enrollment 110 85 100 36 51.2207 Public Health Education and Promotion Fall Enrollment 428 407 390 159 51.2299 Public Health, Other Fall Enrollment 70 69 90 31 Total Public Health 608 561 580 226 17 programs (5-B; 8-M; 4-D) UNC Chapel Hill School of Public Health Response Dramatic changes in the organization, delivery, and financing of public health services are creating new expectations and imperatives for public health organizations at all levels of government and for the private sector. It is the role of the School of Public Health to ensure that public health organizations, programs, services, and personnel respond effectively to these changes and adapt to the new population health needs that arise from these challenges. Public health organizations face a complex array of challenges stemming from demographic, biological, technological, socio-cultural, political and economic trends. Many of these trends are national in scope, yet their effects are felt with varying intensity at regional and local levels. Other trends are specific to individual localities and regions and the political and economic forces affect these areas. Some of the most pressing trends and issues include: Changes in health services delivery and financing Shifts in socio-demographic composition through the aging of the population and a rapidly growing immigrant population Increase in the numbers of uninsured and underinsured persons Emerging and resurgent health risks such as bioterrorism and drug-resistant infectious agents Increased governmental and public pressure for accountability and responsiveness in the health care professions Rapid development of new health and communications technologies such as gene sequencing and diagnostic electronics Downturn in the national and state economy Current state budget crisis Two workforce shortage issues are of particular importance in North Carolina: 68

First, in this state most resources for public health are budgeted and expended locally. Because economic prosperity is not evenly distributed throughout the state, there are significant pockets of medically under-served populations and concomitant health disparities. The greatest opportunity for improving the overall health status of North Carolinians lies in improving services to, and ultimately the health status of, the medically disadvantaged. Second, the demographics of public health staff often do not reflect the demographics of the populations they serve. African-Americans have long been under-represented in public health professions. Now with the influx of Hispanics into the state, the problem is intensified. Training public health staff and leadership in the development and delivery of culturallysensitive health programs, and in the recruitment and retention of a diverse workforce, is essential if we are to show marked improvement in the health status of minorities, who are disproportionately represented among the medically under-served. Public Health Workforce Training Issues A little over a decade ago, the Institute of Medicine s landmark report, The Future of Public Health, identified critical gaps in the workforce capacities of public health organizations gaps that contributed to the apparent disarray of public health. The gaps, however, should not have been surprising, given that both the definition and practice of public health have been evolving with unprecedented speed. The traditional definition of public health is changing rapidly and dramatically. Once the exclusive domain of government-supported local public health departments, the health of the public is now a shared responsibility of many beside governmental public health, including hospitals, managed care organizations, physicians in private practice, businesses and industries, community service agencies and citizens groups. In order to work together effectively, this diverse public health workforce of the new century, a large number of whom have inadequate public health training in preparation for their positions, will need to develop an understanding of the multidimensional nature of the determinants of health. In 1997, the federal Department of Health and Human Services estimated that as much as 80% of the public health workforce had no formal training in public health practice. It desperately needs continuing education and training that are timely, efficient, and cost effective. As we have seen recently with the apparent dissemination of anthrax as an agent of terror, the health crises of the 21 st century may develop unexpectedly, swiftly and broadly. The public health system must be informed, agile, and prepared. The practice of public health is also changing. A century ago public health focused on communicable disease, occupational health, and the environment. By mid-century the scope of the discipline had expanded to reproductive health, chronic disease prevention, and injury prevention. Now, at the century s turn, the focus is increasingly on new issues like genomics, hazardous waste, preventing bioterrorism and violence, and re-emerging issues such as sexually transmitted diseases, tuberculosis, and drug-resistance in once-conquered infectious diseases. Despite the new participants in public health and new trends in health care funding, many governmental public health agencies assumed an increasing burden for the personal care of indigent populations and had less time and fewer resources to carry out other core functions such as community health assessment and planning, policy development, and environmental health. 69

In the years following the IOM report, a variety of initiatives were undertaken to reorient public health organizations around core functions and competencies, to develop the next generation of public health leaders and managers, to develop the discipline-specific skills of core public health professionals such as epidemiologists, health educators, public health nurses, sanitarians, and maternal and child health specialists, and to expand training in public health to the broader audience of health care providers. The UNC School of Public Health was an active participant in these initiatives from the beginning. The School of Public Health Response The mission of the UNC School of Public Health is to advance the public s health through learning, discovery, service, and practice. Its aim is to achieve these outcomes through integrated approaches to teaching, scientific inquiry, public service, and public health practice that benefit the people of North Carolina, the nation, and the world. The UNC School of Public Health has been at the forefront of academic institutions working to untangle the disarray of public health, and maintains that stature today. Workforce development, from entry level to experienced professional, is one of its major strengths. The School offers a complete range of programs that support lifelong learning for public health professionals. At the career entry level, degree programs create new public health practitioners and researchers trained specifically in and for public health. Baccalaureate, masters and doctoral degrees provide in-depth knowledge and skills in specific disciplines of public health (biostatistics, epidemiology, environmental sciences and engineering, health behavior and health education, health policy and administration, maternal and child health, public health and occupational nursing, and nutrition) and in public health leadership. Most masters degree students participate in a field experience of some type during their program of study to gain a first hand knowledge of public health as it is actually practiced in communities. Certificate programs and distance learning and executive masters degrees offer for-credit training by which working public health professionals can gain the basic grounding or special knowledge necessary to fill gaps in their training backgrounds. Topical continuing and executive education programs, also aimed at working professionals, present up-to-date, practical information to enhance public health leadership, administration, and service delivery. Finally, websites, webcasts, and other distance learning programs accessible to both practitioners and the public contribute to a wider understanding of current topics in public health. Since its inception in 1936, the School has placed a fundamental emphasis on service to the state. As an emissary of one of the South s preeminent public universities, the School has always had a vital relationship with the people of North Carolina. It seeks continually to strengthen this relationship, and the School s extensive service activities are well received by the community. Although the face and nature of public health have changed over the last 50 years, the School s commitment to service and practice has remained strong. Over the last three decades, the School has maintained an administrative entity that provides a locus for the service and practice activities of faculty and students. First housed in a unit called the Division of Community Health Service, the School s service and practice functions were, in the mid-nineties, reorganized into a 70

Center for Public Health Practice and finally, today, reside in the North Carolina Institute for Public Health (NCIPH). The North Carolina Institute for Public Health The NCIPH is an administrative unit created in August 1999 to connect the School of Public Health with the people and health organizations of North Carolina, with a mission of improving the health of all the state s citizens. It accomplishes this mission by developing, applying, and disseminating the information needed to improve health decisions at personal, professional, institutional, and public policy levels. NCIPH participants and clients include executive branch agencies of state government, local public health departments, county government elected and appointed officials, purchasers of health care, health care providers, insurers and managed care organizations, nonprofit community organizations, and students involved in the health professions and public policy disciplines. NCIPH provides client-driven training, consulting and technical assistance, and applied research. Products and services include: Conducting workforce development and training programs Assessing and evaluating state and local health needs, programs, and policies Providing consultation and technical assistance to address special issues and meet immediate local needs Informing, analyzing, and planning public policies that affect the public s health Reviewing, synthesizing, and disseminating new knowledge and best practices To accomplish its mission, the Institute relies primarily on its committed staff and the expertise of the faculty of the School of Public Health. The School s faculty and their students are leaders in research on the core issues of public health and health care, and have a long history of service to North Carolina. The Institute helps bridge the gap between public health knowledge and practice by facilitating through these personnel the timely and effective application of academic and research resources to the state s complex health issues. The NCIPH conducts its work in three main program areas: workforce development, consultation and technical assistance, and special programs and applied research. Workforce Development Programs Executive and Outreach Education. The Institute s workforce development program area houses several large executive education and outreach education programs and the School of Public Health s Office of Continuing Education. These executive education and outreach education programs include: a National Public Health Leadership Institute to strengthen the leadership competencies of senior level public health officials from national, state and local health departments, hospitals, HMOs, government health agencies, and health related businesses and organizations; 71

the Management Academy for Public Health, a joint UNC School of Public Health/Kenan Flagler Business School initiative focused on improving the efficiency and effectiveness of management personnel in state and local public health organizations; an academic Certificate in Core Public Health Concepts, a completely on-line academic curriculum of five courses consisting of a basic course in each of the five core subject areas of public health; the Southeast Public Health Leadership Institute, a regional training program aimed specifically at public health leaders from North Carolina and four neighboring states; the Southeast Public Health Training Center, a regional collaboration of academic and practice institutions in North Carolina and neighboring states to assess training needs in the public health workforce and to identify and catalogue training opportunities. Special emphasis is placed on distance learning products accessible by practitioners with limited training resources; Public Health Grand Rounds, a series of Internet webcasts of expert-led discussions of current public health issues and challenges constructed around case studies; the North Carolina Center for Public Health Preparedness, a North Carolina-focused initiative to prepare the state s public health workforce to respond to emerging health threats in general and to bioterrorism in particular; and the North Carolina Occupational Safety and Health Educational Resource Center, a collaboration between the UNC School of Public Health and Duke University to provide training in the areas of environmental hazards and industrial safety. With the exception of the Certificate in Core Public Health Concepts and the Southeast Public Health Leadership Institute, which receive support from the state of North Carolina, these programs are funded by grants from federal agencies and foundations. North Carolinians benefit from local participation in all of these important programs. Continuing Education. The School of Public Health Office of Continuing Education (OCE) offers the largest, most comprehensive continuing education program among the nation s accredited schools of public health. Its role in providing post-graduate professional continuing education to the public health workforce in North Carolina is unsurpassed. OCE annually presents over 150 courses to an audience of more than 15,000 health and human service professionals from state and local settings, federal agencies, hospitals, mental health agencies and managed care organizations. The School s continuing education reach is geographically extensive: for example, in 20000-2001 406 sites were utilized, more than eighty percent of them outside of Chapel Hill, in 41 cities representing 35 counties. OCE programs are delivered in a variety of formats, including face-to face conferences, workshops, short courses and seminars as well as videoconferences, satellite broadcasts, webcasts and interactive web-based instruction. Faculty members from the School direct, develop and present continuing education courses, as do experts and professionals from a variety of agencies. Speakers also include faculty and professionals from other UNC schools and departments, other educational institutions, community and private organizations, and federal 72

and state agencies. These personnel, with administrative and logistical support of a talented OCE staff, present a wide variety of courses and activities focusing on public health practice, research, policy and emerging issues. Consultation and Technical Assistance. Through its consultation and technical assistance program area, the NCIPH serves as an agent to link the public health practice community with the faculty, students and staff in the School of Public Health who can provide information, advice or direct service to help address professional, institutional or policy level issues. The Institute s consultation and technical assistance projects are client-driven and vary widely as to client type, geographic location, and scope and duration of work. The NCIPH has provided technical assistance to state health agencies, local health departments and district health departments, community-based health organizations, and Area Health Education Centers (AHEC) as well as private sector health care providers. Services offered by the NCIPH include assessment, planning and evaluation, identification of best practices, policy analysis, media relations and technical writing. Most technical assistance projects are funded by grants or through contracts. Special Programs and Applied Research. Through its special programs and applied research focus, the Institute also fosters and develops a variety of working partnerships throughout the public health practice community. Office of AHEC and Field Services. The AHEC and Field Services Office in the NCIPH coordinates the training and education activities jointly sponsored by the UNC School of Public Health and the nine regional AHEC offices. It also serves as the liaison between the regional AHECs and the School s faculty, staff and students whose activities are supported by AHEC travel funds. These activities include student field training and faculty and staff travel to continuing education programs, technical assistance visits, and other teaching and program activities. The AHEC and Field Services Office also maintains an extensive database to catalogue the service activities of the School s faculty and professional staff, who annually conduct a total of nearly one-thousand activities or projects amounting to over 25,000 hours of service. North Carolina Prevention Partners. The N.C. Prevention Partners (NCPP) program works to improve the health of North Carolinians throughout the state by bringing attention to the importance of prevention as a strategy. The organization fosters partnerships for prevention, educates the public and professionals, facilitates new prevention efforts, evaluates prevention efforts, and influences policies for prevention. Future Plans To maintain and improve the effectiveness of our state s public health systems, training and technical assistance are urgently needed to ensure that public health workforce possess the most current knowledge and skills available in order to address the evolving public health issues that face our communities. The School is committed to maintaining and expanding academic programs for preparing the public health workforce of tomorrow, and to developing and 73

strengthening continuing education programs and executive education initiatives in leadership and management to improve the skills of the workforce already in place. Due to recent events of frightening import, education for bioterrorism preparedness is a critical need. The School, through the NCIPH, is working with the state Division of Public Health to plan for utilizing anticipated federal funding to expand and enhance the state s bioterrorism preparedness. The School expects to play a critical role in workforce assessment, training and evaluation as a service provider in the state s plan. In addition, the School has recently announced a credit-bearing academic certificate program in Bioterrorism and Emergency Preparedness, and the OCE has produced a Chemical and Bioterrorism Training Workshop in what will be the first in a series of educational opportunities for professionals and the public. Through its Center for Public Health Preparedness, the NCIPH plans also to expand its on-line offerings on a variety of bioterrorism-related topics for a broad audience of practitioners. In order to address the public health impact of the rapidly growing field of genomics, the School, through its recently funded Center for Genomics and Public Health, will work to help translate current research in the field into policy, technical assistance, and training at the state and local levels. The School plans to further its efforts in assessment of public health workforce training needs throughout the state, and to develop cost-effective training and technical assistance programs to address those needs. With speed of information dissemination becoming of increasing importance, the School hopes to expand its capacity in distance learning, both in technological infrastructure and in personnel. It plans to continue to develop, adapt or convert training products for a variety of distance delivery formats, including especially stand-alone formats such as CD ROM, interactive web, and webcasting. The School plans to continue to aggressively seek external funding support to strengthen ongoing educational programs, to develop new programs, and to conduct the basic and applied research in public health that ultimately informs training. Possible Obstacles to Success The School s success in carrying out its plans will be dependent largely on resources of money and personnel. It is apparent that state funding capacity is somewhat fragile, and federal funding for public health, although increased this year, will not target all needs. State level financial uncertainty will be apparent at the local level, too. With local health agencies enduring travel and other budget cuts, fewer agency personnel will be able to participate in continuing education and other training programs. Foundations and private philanthropies, while sympathetic to health needs, tend to view public health funding as the responsibility of the state. Finally, the expertise necessary to provide content on certain urgent training needs such as bioterrorism, emerging infectious diseases, and genomics is in high demand and short supply. 74

Additional Plans that Depend on New Resources The School would like to extend training in prevention and population health to more of the non-traditional public health workforce, such as hospitals, managed care organizations, physicians in private practice, mental health professionals, social service providers, and workplace occupational health. The School is committed to finding and overcoming health disparities in North Carolina, a necessary part of which will be increasing the number of minorities in the public health workforce. The School would like to strengthen its educational outreach to the minority community by expanding educational partnerships with historically black institutions. Direct recruitment of minorities to public health has not been entirely successful, but it may be possible to increase minority representation in the field by providing practitioners such as physicians and nurses exposure to the principles, practices and opportunities of population health. The UNC Chapel Hill School of Public Health has made no funding reductions in its workforce preparation programs other than those temporary and permanent reductions ($1,282,672 this fiscal year) mandated by the current state budget shortfall. AHEC Planning Encompasses the Following: Support growth of distance degree programs to strengthen leadership of public health system. Expand training of other health professionals in prevention and population health issues. Increase linkages to primary care residencies. Create seminar scholarships within the North Carolina Institute of Public Health to expose more practitioners to the principles of leadership in public health. Develop a web-based training program for physicians on public health principles and practices. Continue to develop resources and conduct training in the area of bioterrorism. Expand AHEC Program activities related to tobacco use and prevention. Provide continuing education programs for health care professionals including a continuum of knowledge and skill development, from beginning the conversation to more intensive cessation interventions. The goal would be to reach providers in all practice settings. Expand opportunities for students, during community rotations, to receive training in best practices in counseling patients and educating the general public about tobacco use, prevention, and cessation. 75

NORTH CAROLINA COMMUNITY COLLEGE SYSTEM REPORT TO JOINT LEGISLATIVE HEALTH CARE OVERSIGHT COMMITTEE AND JOINT LEGISLATIVE EDUCATION OVERSIGHT COMMITTEE Session Law 2001-491, Senate Bill 166, Section 8.11 James J. Woody, Jr., Chair State Board of Community Colleges H. Martin Lancaster, President North Carolina Community College System 76 SBCC 03/15/02