Assessing Critical Access Hospital (CAH) Assets & Capabilities for Recruiting and Retaining Physicians: The Wisconsin Community Apgar Program Presented by: David Schmitz, MD, FAAFP Ed Baker, PhD Associate Director of Rural Family Medicine Director, Center for Health Policy Family Medicine Residency of Idaho Boise State University Tom Jones Research Consultant Wisconsin Office of Rural Health University of Wisconsin-Madison School of Medicine and Public Health Presented to: Wisconsin Office of Rural Health Date: June 28, 2012 Presentation Overview Background/Purpose/Development Wisconsin Comparative Database Results Examples from Hospital Level Report Next Steps Questions/Comments for Discussion Findings from the National Apgar Database 1
Acknowledgements John Eich, Director, Wisconsin Office of Rural Health, University of Wisconsin-Madison, School of Medicine and Public Health Funding provided by Health Resources and Services Administration, Office of Rural Health Policy Medicare Rural Hospital Flexibility Program Boise State University Center for Health Policy Research Staff Sean Wasden, MHS, Research Assistant Lisa MacKenzie, Graduate Research Assistant Bradley Morris, Undergraduate Research Assistant Background How did we get here Why research? Boise State University: Ed Baker, PhD Family Medicine Residency of Idaho: Dave Schmitz, MD Office of Rural Health and Primary Care: Mary Sheridan An intersection of, education and advocacy Practical knowledge, relationships, experience and investment Answering needs and necessary questions Applied research: Development of tools Partnerships with those with skin in the game 2
Purpose of the Critical Access Hospital CAQ (CAH CAQ) A validated tool used to assess a rural community s assets and capabilities in recruiting and retaining family physicians. This should accurately correlate to historical community-specific trends. Designed to be a real-time assessment tool providing guidance for the most helpful interventions at the present. Purpose of the CAH CAQ (cont.) Presentation of individual CAQ Scores facilitating discussions with key decision makers in each community for specific strategic planning and improvements The CAH CAQ can also be used to track a community s progress over time, similar to the clinical use of Apgar scores in newborns. 3
CAH CAQ Development Goal Develop an objective measurement tool (CAH CAQ) to assess the characteristics and parameters of rural Idaho communities related to successful recruitment and retention of family physicians Process Research the scientific literature Site visits to rural Idaho communities Discussions with rural physicians and hospital administrators CAH CAQ Development The CAH CAQ Questions aggregated into 5 Classes Geographic Economic Scope of Practice Medical Support Hospital and Community Support Each Class contains 10 factors for a total of 50 factors/questions representing specific elements related to recruitment and retention of family medicine physicians in rural areas Three open-ended questions 4
CAH CAQ Development: Class/Factor Examples Geographic Schools Climate Perception of Community Spousal Satisfaction Economic Loan Repayment Competition Part-time Opportunities Signing Bonus Scope of Practice Emergency Care Mental Health Obstetrics Administration Duties Medical support Nursing Workforce Call/practice Coverage Perception of Quality Specialist Availability Hospital and Community Support EMR Welcome & Recruitment Televideo Support Plan for Capital Investment Use of the CAH CAQ: Wisconsin Sample and Administration CAH CAQ Target Communities in Wisconsin 12 critical access hospitals 12 hospital administrators and 12 physicians for a total sample of 24 CAH CAQ Administration for Year 1 of Program Participants mailed the CAH CAQ survey in advance with consent form [IRB approval from Boise State University] and one hour interviews scheduled Separate structured one hour interviews for each participant where consent form was reviewed and executed and CAQ completed 5
Use of the CAH CAQ: Wisconsin Analyses and Reporting Wisconsin Analyses Development of a Wisconsin comparative database for physician recruitment and retention Statewide technical report and presentation for Year 1 results 12 critical access hospital individual Board reports each year of the program CAH CAQ Board Reports Individual data from each Wisconsin critical access hospital reviewed with Board of Directors of each facility each year of the program Action plans developed in Year 1 for improvement in areas identified by the CAH CAQ Year 2 review focuses on movement towards achieving improvement identified in Year 1 Making the most of the CAH CAQ Recruiting and Retaining Family Physicians: community self-evaluation prioritizing improvement plans advertising and interviewing negotiation strategies and contract construction 6
The CAQ Value Proposition Beyond Expert Opinion A new approach to the old problem of physician recruiting Self-empowering for the community: knowledge as power, not an outside headhunter Beyond physician recruitment to community improvement Future of the CAH CAQ With further research and collaboration, this tool could also be used to share successful strategies communities have used to overcome challenges which may be difficult or impossible to modify. CAH CAQ surveys may be useful in identifying trends and overarching themes which can be further addressed at state or national levels. 7
States Participating/Interested States Participating in the CAP States Interested in Implementing the CAP Wisconsin Comparative Database Results 8
Class CAH Community Advantages and Challenges Cumulative Score 1 Overall Administrator Physician 11.00 1 9.00 8.00 Cumulative Score 7.00 6.00 5.00 4.00 3.00 1.00 Medical Support Economic Hospital and Community Support Scope of Practice Geographic Community Advantages and Challenges Class Summary Class CAH Community Advantages and Challenges "Overall" Administrator Physician 40 35 30 Cumulative Score 25 20 15 10 5 0 Respondent 9
Top 10 CAH Community Advantages Overall 1.50 1.00 0.50 Recreational Employment status Income guarantee Nursing Religious, cultural Community volunteer Ancillary staff Perception of quality Transfer arrangements Mid-level provider Top 10 Factors- Advantages Top 10 CAH Community Advantages (Continued) Overall 1.50 1.00 0.50 Community need, physician support Top 10 Factors- Advantages 10
Top 10 CAH Community Challenges Overall 1.50 1.00 0.50-0.50-1.00-1.50 - Spousal satisfaction Televideo support Inpatient care Shopping and other services Social networking Electronic Mental health Climate C-section Obstetrics medical records Top 10 Factors- Challenges Class CAH Community Importance Cumulative Score 35.00 Overall Administrator Physician 3 25.00 Cumulative Score 2 15.00 1 5.00 Economic Medical Support Geographic Hospital and Community Support Scope of Practice Community Importance Class 11
Summary Class CAH Community Importance Overall Administrator Physician 160 140 120 Cumulative Score 100 80 60 40 20 0 Respondent Top 10 CAH Community Importance 4.00 Overall 3.50 3.00 2.50 1.50 1.00 0.50 Schools Employment status Perception of quality Physical plant and equipment Spousal satisfaction Revenue flow Physician stability Obstetrics Emergency room coverage Call, practice coverage Top 10 Factors- Importance 12
Class CAH Community Apgar Cumulative Score 35.00 Overall Administrator Physician 3 25.00 Cumulative Score 2 15.00 1 5.00 Economic Medical Support Hospital and Community Support Scope of Practice Geographic Community Apgar Class Summary Class CAH Community Apgar Overall Administrator Physician 120 100 Cumulative Score 80 60 40 20 0 Respondent 13
Geographic Class CAH Community Apgar 8.00 Overall Administrator Physician 6.00 4.00 - -4.00-6.00-8.00 Recreational Religious, cultural Schools Demographic, patient mix Access to larger community Perception of community Climate Social networking Shopping and other services Spousal satisfaction Geographic Factor Economic Class CAH Community Apgar 8.00 Overall Administrator Physician 6.00 4.00 - -4.00-6.00-8.00 Employment status Income guarantee Revenue flow Start-up, marketing costs Part-time Moving allowance Competition Loan repayment Payor mix Signing bonus Economic Factor 14
Scope of Practice Class CAH Community Apgar 8.00 Overall Administrator Physician 6.00 4.00 - -4.00-6.00-8.00 Emergency room coverage Nursing home Administration Teaching Endoscopy, surgery C-section Obstetrics Mid-level supervision Mental health Inpatient care Scope of Practice Medical Support Class CAH Community Apgar 8.00 Overall Administrator Physician 6.00 4.00 - -4.00-6.00-8.00 Perception of quality Nursing Physician stability Ancillary staff Transfer arrangements Mid-level provider Emergency medical services Specialist availability Allied mental Call, practice health coverage Medical Support 15
Hospital and Community Support Class CAH Community Apgar 8.00 Overall Administrator Physician 6.00 4.00 - -4.00-6.00-8.00 Community volunteer Community need, physician support Welcome and recruitment Internet access Physical plant Plans for capital Hospital and equipment investment sponsored CME Hospital and Community Support Hospital leadership Electronic medical records Televideo support Top 10 CAH Community Apgar 8.00 Overall 6.00 4.00 - -4.00-6.00-8.00 Employment status Recreational Perception of quality Income guarantee Nursing Religious, cultural Physician stability Transfer arrangements Ancillary staff Community volunteer Top 10 Factors- Apgar 16
Top 10 CAH Community Apgar (Continued) 8.00 Overall 6.00 4.00 - -4.00-6.00-8.00 Revenue flow Top 10 Factors- Apgar Bottom 10 CAH Community Apgar 8.00 Overall 6.00 4.00 - -4.00-6.00-8.00 Spousal satisfaction Televideo support Inpatient care Shopping and other services Mental health Social networking Climate Electronic medical records Perception of community Mid-level supervision Bottom 10 Factors- Apgar 17
Cumulative CAH Community Apgar Score Wisconsin Hospitals 400 350 300 Cumulative CAH Apgar Score 250 200 150 Apgar Score Apgar Average 100 50 0 2 3 7 8 6 10 1 12 9 4 5 11 Critical Access Hospital Code Examples from Hospital Level Reports 18
Hospital X Comparative Cumulative Apgar Score Baseline Mean Osceola Medical Center 30 25 20 Cumulative Apgar Score 15 10 5-5 Overall Apgar Geographic Economic Scope of Practice Medical Support Hospital and Community Support Community Apgar Class Hospital X Comparative Cumulative Apgar Score Baseline Mean Flambeau Hospital 25 20 Cumulative Apgar Score 15 10 5-5 Overall Apgar Geographic Economic Scope of Practice Medical Support Hospital and Community Support Community Apgar Class 19
Hospital X Comparative Cumulative Apgar Score for Geographic Class Baseline Mean Reedsburg Area Medical Center 2 15.00 1 Cumulative Apgar Score 5.00-5.00-1 -15.00-2 Access to larger community Demographic, patient mix Social networking Recreational Spousal satisfaction Schools Geographic Factors Shopping and other services Religious, cultural Climate Perception of community Hospital X Comparative Cumulative Apgar Score for Economic Class Baseline Mean The Richland Hospital Inc 2 15.00 1 Cumulative Apgar Score 5.00-5.00-1 -15.00-2 Employment status Part-time Loan repayment Income guarantee Signing bonus Moving allowance Start-up, Revenue flow Payor mix Competition marketing costs Economic Factors 20
Hospital X Comparative Cumulative Apgar Score for Scope of Practice Class Baseline Mean Wild Rose Community Memorial Hospital 2 15.00 1 Cumulative Apgar Score 5.00-5.00-1 -15.00-2 Obstetrics C-section Emergency room coverage Endoscopy, surgery Nursing home Inpatient care Mental health Mid-level supervision Teaching Administration Scope of Practice Factors Hospital X Comparative Cumulative Apgar Score for Medical Support Class Baseline Mean Black River Memorial Hospital 2 15.00 1 Cumulative Apgar Score 5.00-5.00-1 -15.00-2 Perception of quality Physician stability Specialist availability Transfer arrangements Nursing Allied mental health Mid-level provider Ancillary staff Emergency Call, practice medical services coverage Medical Support Factors 21
Hospital X Comparative Cumulative Apgar Score for Hospital and Community Support Class Baseline Mean Prairie Du Chien Memorial Hospital 2 15.00 1 Cumulative Apgar Score 5.00-5.00-1 -15.00-2 Physical plant and equipment Plans for capital Electronic investment medical records Hospital leadership Internet access Televideo support Hospital and Community Support Factors Hospital Community sponsored CME need, physician support Community volunteer Welcome and recruitment Hospital X Top 10 Apgar Factors across All 50 Factors Overall 8.00 7.00 6.00 5.00 4.00 3.00 1.00 Schools Demographic, patient mix Revenue flow Part-time Recreational Top 10 Apgar Employment status Mid-level provider Nursing Moving allowance Access to larger community 22
Hospital X Bottom 10 Apgar Factors across All 50 Factors Overall 3.00 1.00-1.00 - -3.00-4.00-5.00-6.00 Call, practice coverage Televideo support Welcome and recruitment Loan repayment Social networking Bottom 10 Apgar Community Signing bonus Climate Competition Perception of need, physician community support Hospital X Top 10 Cumulative Apgar Variance Factors across All 50 Factors 14.00 1 1 Cumulative Apgar Score 8.00 6.00 4.00 Obstetrics Call, practice coverage Emergency room coverage Physician stability Internet access Specialist availability Top 10 Apgar Variance Factors Social networking Community need, physician support Community volunteer Religious, cultural 23
Hospital X Bottom 10 Cumulative Apgar Variance Factors across All 50 Factors - -4.00-6.00 Cumulative Apgar Score -8.00-1 -1-14.00-16.00-18.00-2 Access to larger community Perception of community Physician stability Shopping and other services Payor mix Demographic, patient mix Social networking Call, practice coverage Obstetrics C-section Bottom 10 Apgar Variance Factors Next Steps Return in Fall 2012 to re-assess using Community Apgar Questionnaire at original 12 critical access hospitals Develop Year 2 Wisconsin comparative database Develop reports for 12 individual critical access hospitals using updated Year 2 Wisconsin comparative database Present individual reports to 12 critical access hospitals highlighting progress towards action plan goals 24
Questions/Comments for Discussion Findings from the National Apgar Database States Participating in the CAP States Interested in Implementing the CAP 25
Top 10 Apgar Factors Idaho (2008) Wyoming (2010) North Dakota (2011) Wisconsin (2012) Recreational Community need/support of physician Internet access Income guarantee Hospital leadership Plans for capital investment Transfer arrangements Community volunteer Perception of quality Loan repayment (tie for 10 th ) Inpatient care (tie for 10 th ) Employment status Loan repayment Income guarantee Community need/physician support Recreational Revenue flow Competition Ancillary staff Transfer arrangements Moving allowance Perception of Quality Transfer arrangements Internet access Loan repayment Income guarantee Community need/physician support Ancillary staff Employment status Moving allowance Schools Employment status Recreational Perception of quality Income guarantee Nursing Religious/cultural Physician stability Transfer arrangement Ancillary staff Community volunteer (tie for 10 th ) Revenue flow (tie for 10 th ) Bottom 10 Apgar Factors Idaho (2008) Wyoming (2010) North Dakota (2011) Wisconsin (2012) Spousal satisfaction C-section Shopping/other services Schools Mental health Electronic medical records Part-time Social networking Perception of community Allied mental health Spousal satisfaction Shopping/other services Access to larger community Mental health Social networking Allied mental health Religious/cultural Climate Electronic medical records Nursing home Climate Spousal satisfaction Shopping/other services Mental health Access to larger community Emergency room coverage Demographic/patient mix Social networking Allied mental health Electronic medical records Spousal satisfaction Televideo support Inpatient care Shopping/other services Mental health Social networking Climate Electronic medical records Perception of community Mid-level supervision 26