Un-Tapped Resources: Understanding Arizona 3RNet

Un-Tapped Resources: Understanding Arizona 3RNet Presented by: Joyce Hospodar, MBA, MPA Senior Advisor, Rural Programs Center for Rural Health UA MEZCOPH Thursday, March 31, 2016 3:30 PM 4:30 PM

Discussion Points Describe 3RNet Introduce Arizona Partners Define Roles Review how to sign-up, utilize, and improve postings Showcase upcoming national/state website improvements Invite open discussion: Questions TA Needs Other

What is 3RNet? History: Started 20 years ago, celebration in 2015 Purpose: A free, national online rural recruitment and retention tool Az3RNet = Arizona Rural Recruitment and Retention Network

Arizona 3RNet Partnership SORH ACCESS TO CARE RURAL and UNDERSERVED RECRUITMENT and RETENTION PCO PCA

Key Roles of Az3RNet Partners Partner SORH Arizona Center for Rural Health PCO ADHS/ Bureau of Health Systems Development PCA Arizona Alliance for Community Health Centers Key Role Oversees management of website Manages Arizona s workforce programs Recruits/retains workforce at Arizona s FQHCs

Current National 3RNet Website

Current Arizona 3RNet Website

Benefits to Rural/Underserved Health Organizations Free service Significant number of candidates register on Az3RNet Number of postings are unlimited must be healthcare related Resources available to assist you/your organization

Types of Opportunities Sought Family Practice, Internal Medicine Emergency Medicine, General Surgery Nurse, Nurse Practitioner, Physician Assistant Dentist Social Worker, Psychiatry Pharmacy Radiology Human Resources/Administration/Management Laboratory Technician EMS/EMT

Process for Candidate Registration

Steps to Sign Up Visit the Az3RNet website https://www.3rnet.org/locations/arizona On the upper right hand side of the screen click on Employer Registration Complete the Employer Registration form and submit Approval provided by AzCRH to post job openings

Process for Employer Registration

City Locations of Registered AZ Employers

Types of Registered Employers Community Health Centers Critical Access Hospitals Other Rural Hospitals Medical Practices Behavioral Health Organizations Rural Health Clinics County Government Tribal Entities Veterans Administration Medical School Associations Other

Registered Facilities by Year Year Number New Facilities Registered 2013 18 2014 32 2015 38 2016 (Jan-Mar) 7

Example - AZ Opportunity Search

Tips for Effective Site Listings Physician - Internal Medicine URGENT NEED FOR Internal Medicine Physician in Some City, State. J1 Waiver/H1b/National Interest Waiver approved site.. SEND RESUME IMMEDIATELY TO: xxxxx@aol.com Physician - Pediatrics Staff Physician (Pediatrician) opportunity available at the Gold Village Health Centers in Some City, Some State. Applicant must have a medical degree or equivalent and completion of residency in Pediatrics. Must also have or be eligible for State medical license, along with a BC/BE in Pediatrics. If interested, mail résumé to: Nurse Practitioner (NP) - Family Medicine Mid level practitioner needed for a long standing Rural Health Clinic in Some City, Some State.

Tips for Effective Listing Physician - Family Medicine While it's just over a two hour drive from the Bay Area, Bay Valley feels like another world. Within this area, sheep pastures and vineyards alternate with forests of oak and pine that stretch over the distant hills. As you drive along the Navarro River, to the Ocean, Redwood trees tower over the road providing a canopy of peace. Physician - Internal Medicine Board Eligible Internal Medicine Physician: Provides health care services to patients. This opportunity will allow you to work collaboratively with a multi-disciplinary team of professionals not only addressing the treatment of disease, but focusing on the healing process, prevention of illness, and optimal wellness of patients. Physician - Obstetrics & Gynecology FQHC with 40 years of Commitment and Success Diamond FQHC Values are Advocacy, Access, Respect, Efficiency, Innovation & Excellence. Join our premier organization to help ensure access to high quality, culturally responsive and comprehensive Primary healthcare to all in our communities.

Additional Ideas to Improve Postings Solicit quotes from recently placed providers from region Post photos of newly hired practitioners from region Highlight communities/facilities on region page with text, photos, etc. What ideas do you have? What has worked best for your organization?

Proposed New National 3RNet Website

Proposed New State Page

Open Discussion Questions? Technical Assistance needs? Other?

Az3RNet Contacts Partner Websites AzCRH ADHS BHSD AACHC Joyce Hospodar, MBA, MPA Senior Advisor, Rural Programs 520.626.2432 hospodar@email.arizona.edu Rebecca Ruiz Senior Program Coordinator 520.626.2243 raruiz@email.arizona.edu Ana Lyn Roscetti, MPH Workforce Section Manager 602.542.1066 ana.lyn.roscetti@azdhs.gov Lourdes Paez Workforce Development Programs 602.288.7550 lourdesp@aachc.org www.crh.arizona.edu www.azdhs.gov/hsd/ www.aachc.org

Thanks!!

Apprenticeship Within the Workforce System The other 4 year Degree Building a Skilled Workforce for the 21 st Century An Equal Opportunity Employer/Program Auxiliary Aids and Services available upon request to individuals with disabilities

Presentation Overview: What is the Apprenticeship Program? Collaboration with Workforce Innovation Opportunity Act (WIOA) Setting Up an Apprenticeship Program

What is Apprenticeship? IT S EMPLOYMENT Combines on-the-job training (OJT) & related training instruction (RTI) Progressive pay scale Supervised by qualified mentors Occupation Specific: 1-6 years in length Nationally Recognized Credential Time-tested training system

Various Industries: Programs can be established in many industries, including: Health Care Geospatial Technology Aerospace Informational Technology Construction Social Services Financial Services Manufacturing Retail Childcare Hospitality Energy Security Automotive

Apprenticeship Benefits to Business Attracts Focused Applicants Equips workers with problemsolving expertise Identifies defined career path; provides growth opportunity Increases Retention Raises skill level of employees Cultivates a loyal and knowledgeable employee Pipeline for future management

Apprenticeship Local Workforce Area Benefits-Youth Apprenticeship participation results in placement of youth in employment at the conclusion of training Apprenticeship meets the definition of attainment of degree or certificate completion rate

Setting up a Program Job Seeker Starts Employment & Training Standards are Registered Employer Develops Standards & Work Processes Employer Identifies Apprenticeable Occupation

WIOA Apprenticeship Support Strategies OJT for 1 st Year Tools & Training Materials Tuition Assistance (RTI)

Local Workforce Area Performance Measures Apprenticeship programs can track: How many entered employment Retention Earnings Educational attainments Exit wage data

Eligible Training Provider List (ETPL) Registered Apprenticeship programs are automatically approved on the ETPL. They only need to register their information. This enables jobseekers to apply for an Individual Training Allowance (ITA) Veterans can spend their GI Bill in a registered apprenticeship program

Apprenticeship in Arizona (as of 03/22/16) Registered Apprentices in Arizona 2690 Registered Programs in Arizona 121 Traditional Occupations 68 Non traditional Occupations 32%

Registered Apprenticeship Everyone Wins!

CONTACT INFORMATION: Website: www.azapprenticeship.com State Apprenticeship Program Lead William Higgins whiggins@azdes.gov Colleen Henry USDOL Director of Apprenticeship Arizona/Nevada Henry.Colleen@dol.gov

COLLABORATING WITH PA S: RECRUITMENT, ROLES, & RELATIONSHIPS Arizona Alliance for Community Health Centers at the 2016 Arizona Recruitment & Retention Conference March 31, 2016. Randy D. Danielsen, PhD, PA, DFAAPA Dean & Professor Arizona School of Health Sciences A.T. Still University Mesa, Arizona

HISTORY OF PA S Arose in the late 1960s / early 1970s in response to primary care physician shortages in impoverished areas PA training based on shortened MD training during WWII Numbers began to increase dramatically when practices were allowed to bill for their services PAs now practice in almost every medical specialty and in every state PAs are typically paid 50 60% of MD/DO salary, but can bill for 85 100% for services provided 2

INNOVATORS IN THE 1960 s Charles Hudson Doctor Assistant Eugene A Stead, Jr Physician s Assistant Loretta Ford RN and Henry Silver Pediatric Nurse Practioner Innovators John Kirklin Surgeon s Assistant Hu C. Myers PA Baccalaureate Program Richard Smith MEDEX

Over the past 50 years, the PA concept has been shown to be a remarkable workforce policy success: Prescribing in all states Reimbursement through all third-party payers High demand in the medical marketplace Utilization and new roles are expanding Patients accept PAs; a poll showed that 66% of citizens recognize the PA role and one-third have been treated by a PA (AAPA, 2007) The career is attractive with high levels of job satisfaction mean salary is $93,000/year. High levels of job and career satisfaction among PAs. Why is this? One obvious factor: PAs complement physician practices and do not threaten physician roles or authority The PA concept is spreading globally with programs now in Canada, England, Scotland, Australia, Saudi Arabia, Ghana, and the Netherlands PAs have shown remarkable clinical mobility across medical specialties and settings PA S: A WORKFORCE POLICY SUCCESS IN THE U.S. Hooker, RS, Cawley, JF, Asprey, DP. Physician Assistants: Practice and Policy, 3rd Edition. Philadelphia: FA Davis, 2010.

TODAY The PA is a competency-based occupation. Different PAs do different work. It is based on a "negotiated" role between an individual physician and a PA. This makes it unique. It means PAs can do a very wide range of tasks- and can have roles that change and expand significantly over the course of a career. Eugene Schneller

PHYSICIAN ASSISTANTS Each year more than 6,000 PAs are added to the U.S. health workforce. 1 The PA workforce is projected to increase by 58% by 2020 2, 3 By 2025 there are projected to be 125,000 PAs Approximately 1,942 PAs practicing in Arizona A provider ratio of 29 per 100,000 population 1 Demand for America s PAs Surges in New Era of Healthcare AAPA https://www.aapa.org/twocolumn.aspx?id=3311 2 Hooker RS, Muchow, Ashley N. Supply of physician assistants: 2013-2026. Journal of the American Academy of Physician Assistants 2014; 27:39045 3 National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care practitioners Through 2020. U.S. Department of Health and Human Services, Health Resources and Services Administration. Rockville, MD 2013

Source: Page 26

250 200 Non-U.S. Programs U.S. PA Programs Number 150 100 50 0 1960 1965 1968 1972 1976 1980 1984 1988 1992 1996 2000 2002 2004 2006 2008 2010 2012* 2014* 2016* 2018* GROWTH OF PA EDUCATIONAL PROGRAMS Year * Projected 1/4/16 there are 199 ARC-PA Accredited PA Programs in the U.S.

PA SUPPLY PROJECTIONS According to AAPA/NCCPA figures, there are 108,000 PAs practicing in this country (2015)

Supply of physician assistants: 2013-2026, Roderick S. Hooker, PhD, PA; Ashley N. Muchow JAAPA Volume 27 Number 3 March 2014 10

RETIREMENT/ATTRITION/MORTALITY OF PAS 11 Supply of physician assistants: 2013-2026, Roderick S. Hooker, PhD, PA; Ashley N. Muchow JAAPA Volume 27 Number 3 March 2014

COMPARING NPS, PAS, AND MDS NP PA MD / DO Training 2 years part time 2 years full time 7 years minimum, full time (most do at least 8 years). Pre-requisites BSN (+/- experience, although most do have experience) BA or BS in any field + 1-2000 hours experience BA or BS in any field. No experience required Credential Traditionally MSN, moving to DNP MS (most) MD / DO Specialization Chosen at time of application to MSN program. Change of specialty requires additional formal training May change fields at any time if a new employer wishes to hire the individual Choose specialty in 4 th year of training. Change of specialty requires minimum of 3 years full time additional training Recertification None Every 6-10 years Every 10 years (most) Prescribing Yes Yes Yes Ordering Tests / Rads Yes Yes Yes Procedures If trained If trained If trained Independent? Yes in some states, no in others No always works with some level of physician supervision Regulation Board of Nursing Board of Medicine Board of Medicine Salaries High 5 figures to low 6 figures High 5 figures to low 6 figures Low to high 6 figures Yes 12

PA PRACTICE CHARACTERISTICS SPECIALTIES RESPONDENTS (%) Primary Care * 23.6 Surgical Subspecialties 29.1 Internal Medicine Subspecialties 10.9 Emergency Medicine 10.4 Pediatric Subspecialties 1.3 Other Specialties 24.7 Primary care include family medicine, general pediatrics, and general internal medicine PRIMARY SETTING PRIMARY CARE ALL OTHER SPECIALTIES RESPONDENTS (%) Physician Office/Clinic 86.4 37.9 Hospital 4.7 50.8 All Others 8.9 11.3 TYPICAL NUMBER OF PATIENTS SEEN PRIMARY CARE ALL OTHER SPECIALTIES MEDIAN Patients Seen Per Day 17.0 15.0 Patients Seen Per Week 75.0 60.0 American Academy of Physician Assistants. 2015 AAPA Salary Report. Accessed October 8, 2015.

Female 66.6 Male Gender 33.4 Asian 5.1 White, 86.8 PAS BY GENDER AND RACE Race Native Hawaiian or Other Pacific Islander 0.4 Other 3.3 Black/ African American 3.9 American Indian or Alaskan Native 0.5

PA PRESCRIBING Florida just passed legislation to allow PAs to prescribe controlled substances NH WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL GA VT NY PA WV VA NC SC NJ ME MA RI CT DE MD DC AK TX LA FL HI Prescribe including controlled substances Prescribe excluding controlled substances

1. Licensure as the regulatory term 2. Scope of practice determined at the practice site 3. Adaptable supervision requirements 4. Full prescriptive authority 5. Chart co-signature requirements determined at the practice 6. Number of PAs a physician may supervise determined at practice level Source: American Academy of Physician Assistants: State Law Issues: Issue brief. 2011

ISSUE: MORE PATIENTS IN THE SYSTEM Affordable Care Act of 2010 means: Millions of new patients will have insurance and therefore, access to care Increased funding for 15,000 new providers at CHC s Increased funding for PA /Physician training (Title VII) PAs are seen as key players 17

ISSUE: IMPENDING PHYSICIAN SHORTAGE According to the AAMC and other health policy experts: Shortage of 159,000 physicians by 2025 2014 Match Results for US Medical Graduates: 45 % Family Medicine filled with US graduates >90 % Derm, Ortho, ENT, Plastics, Radiation Oncology filled with US graduates Only 2% of IM residents going into general internal medicine practice! Source: American Association of Medical Colleges 18

ISSUE: AMERICA S HEALTH CARE WORKFORCE 800,000 physicians currently practicing Only 1/3 of the U.S. physicians practice primary care The number of young physicians indicating an interest in primary care is static There are approximately 140,000 nurse practitioners (NPs) and 108,000 physician assistants (PAs) practicing in the United States (2015) 19

ISSUE: ACCESS TO PRIMARY CARE Access to primary care is difficult for many people living in rural America 1 Growing number of rural residents who gained health insurance under the ACA will exacerbate the access problem 2 Newly acquired ACA-insured population is estimated to increase the use of physicians by 7.9% 3 Who will provide the additional primary care visits needed? 20

ISSUE: ACCESS TO PRIMARY CARE PAs and NPs provide substantial portions of primary care visits in both rural and urban settings. NPs-19% PAs-7% Both are well positioned to help alleviate physician shortages, especially in rural areas. Patient ourtcomes are similar Patient satisfaction is high Rural Health Research Center Policy Brief #155 March 2016 21

ISSUE: ACCESS TO PRIMARY CARE PA and NPs were used twice as often in CHCs than in private practice Team Practice: 13% of all CHC encounters had an interprofessional (collaborative) involvement A higher percentage of visits to NPs (53%) and PAs (54%) included documentation of health education/preventive services/counseling in the medical record compared to physicians (42%) Hing, E., Hooker, R.S. Roles of Nonphysician Clinicians in Community Health Centers: United States, 2006-2008. NCHS Data Brief. Hyattsville, MD, National Center for Health Statistics, 2011 22

RECRUITMENT OF PA S Integrating Physician Assistants into your practice involves many steps: 1. Assessing organization s practice culture for PA fit 2. Evaluation of current and future productivity of physicians and PAs 3. Developing a formal job description 4. Creating a compensation plan (Salary, benefits, license fees, CME, membership dues, incentives) 5. Recruiting 6. Orientation/Training 7. Performance

RECRUITMENT OF PA S Local market supply Traditional online/newspaper postings Networking with PA programs National Professional meetings/conferences Consider staffing time, candidates will need to obtain state license

RECRUITMENT OF PA S

A successful team requires trust, communication, current, evidence-based practice guidelines, feedback and experience Although state laws vary regarding the extent of practice and level of supervision for PAs, hospitals and physician groups may independently set their own standards for supervision 26

SHAPING GREAT PHYSICIAN-PA TEAMS Great Physician-PA teams were featured in an earlier NCCPA Foundation study (and featured in an award winning documentary) which reported five key success factors in shaping good teams! Source: http://www.paexcellence.org/programs/programs_best_practices.html 27

FIVE KEY SUCCESS FACTORS FOR SUCCESSFUL PHYSICIAN-PA TEAM Shared Priorities Consistency of the Delivery of Patient Care Frequent & Effective Communication Physician Accessibility & Approachability Mutual Trust & respect 28

PA SUPERVISION/COLLABORATION --TYPES Prospective supervision Writing and reviewing the assessment and treatment guidelines Establishing when and under what circumstances physician intervention is required Concurrent supervision Reviewing patients on a real-time basis based on departmental guidelines or ad hoc Retrospective supervision An after-the-fact review of charts 29

PA workforce capacity can help meet the burgeoning demand for primary care RECOMMENDATIONS 1. Expand PA training sites which will enhance the likelihood of practice in rural areas after graduation 2. Consider Home Town applicants to PA School. 3. Encourage loan repayment and forgiveness opportunities for PAs.* 4. Support payment policies that compensate equally for specific primary care services regardless of whether they are provided by an MD, DO, PA or CNP *According to the NCCPA, 19.3% of recently certified PAs indicated that student debt influenced their decision to seek a primary care or non-primary care position

PA RESOURCES The Preceptor s Handbook for Supervising for Supervising Physician Assistants http://www.jblearning.com/catalog/9780763773618/ AAPA www.aapa.org NCCPA www.nccpa.net PAEA http://paeaonline.org ARC-PA www.arc-pa.org 31

QUESTIONS? Thank You!

Shortage Designations 101 Medically Undeserved Areas/Populations (MUA/Ps) Health Professional Shortage Areas (HPSAs) March 31, 2016 Tracy Lenartz, MPH Contractor Bureau of Health Systems Development Arizona Department of Health Services Health and Wellness for all Arizonans

Shortage Designation Program Purpose: Designations identify areas or populations as having a shortage of or need for dental, mental, and primary health care providers/services Types of Federal Designations: Medically Underserved Area (MUA) and Medically Underserved Population (MUP) Primary Care only Health Professional Shortage Area (HPSA) Primary Care, Dental, Mental Health Health and Wellness for all Arizonans

Medically Underserved Areas Federal designation that identifies areas as medically underserved based on demographic data Area must be rational (similar demographics and care-seeking patterns) follow pre-approved AZ Rational Service Area plan when possible Area is scored on 4 criteria: Percentage of population below poverty level Percentage of population 65 and over Infant mortality rate Primary care physicians per 1,000 population Health and Wellness for all Arizonans

MUAs, Continued Each of the 4 criteria is given a score with a weighted value. Sum of scores = Index of Medical Underservice (IMU) Scale from 0 to 100 0 = completely underserved, 100 = best served Any rational service area with a score equal to or less than 62.0 qualifies for MUA designation Health and Wellness for all Arizonans

Medically Underserved Populations Used when area does not qualify as MUA Same data elements and computations as MUA Difference = Use requested group within area as population, rather than total resident civilian population Often use low income (under 200% FPL) population for MUPs Health and Wellness for all Arizonans

MUA/MUP Designation Process Not a competitive process - Any individual or agency may submit a designation request to the Bureau of Health Systems Development (HSD) HSD will evaluate the request and assess area If area qualifies - HSD submits formal request to federal Shortage Designation Branch (HRSA) If designated, published online and in federal register Complete designation process can take 6-12 months MUA/MUP designations currently are not required to be updated Health and Wellness for all Arizonans

Health Professional Shortage Areas Health Professional Shortage Area (HPSA) designation identifies an area or population as having a shortage of providers Primary Care Dental Mental Health HPSA designations are used to qualify for state and federal programs aimed at increasing primary care services to underserved areas and populations Health and Wellness for all Arizonans

Types of HPSAs Geographic Geographic with high needs (i.e. > 20% poverty) Population (i.e. Low Income) Facilities: State and Federal Correctional Facilities Some facility types are eligible for an automatic HPSA designation Federally Qualified Health Centers (FQHCs) and Look-Alikes Rural Health Clinics (RHCs) must certify they see all regardless of ability to pay Indian Health Service/Tribal done as a Native American Population HPSA Health and Wellness for all Arizonans

Geographic Area A rational service area - in Arizona we use an established Primary Care Area plan Based on demographics and care-seeking patterns Population to Provider Ratio Requirement: 3,500:1 Counts only MDs and DOs in primary care: family/general practice, internal medicine, and Ob/Gyn (does not include mid-level providers) Does not include obligated providers (NHSC, J-1, federal commissioned officers) Health and Wellness for all Arizonans

Geographic Area with High Needs A rational service area that exhibits one of the following: 20% or more of the population is @ 100 % of the poverty level Infant mortality rate is greater than 20 Population to Provider Ratio Requirement: 3,000:1 Health and Wellness for all Arizonans

Population Low Income Population = Those below 200% FPL in rational service area Providers = just those seeing patients on AHCCCS or a sliding fee scale Population to Provider Ratio Requirement: 3,000:1 Health and Wellness for all Arizonans

Excluded from Provider FTE Count NHSC Federal Scholarship or Loan Repayment Providers Other Federal providers (e.g. Commissioned Officers) Physicians who are graduates of foreign schools who are not citizens or lawful permanent residents (including those with J-I or H1-B visas) Providers engaged solely in admin, research, or teaching Physicians involved exclusively in inpatient or ER care Providers full-time in correctional institutions Providers suspended under provisions of the Medicaid-Medicare-Anti-Fraud and Abuse Act for a period of 18 months or more Health and Wellness for all Arizonans

Contiguous Areas Must show population of proposed HPSA cannot get services in surrounding service areas Can rule out contiguous areas due to: Over-utilization (>2,000:1) Excessive Distance (> 30 minutes) Significant socioeconomic differences Designated as HPSA Inaccessible for other reasons (i.e. reservation services only available to tribal populations) Health and Wellness for all Arizonans

HPSA Designation Process ADHS Bureau of Health Systems Development gathers data and submits applications to federal HRSA office HRSA analyst reviews and approves/rejects for designation If designated, published online and in federal register HPSA designations last for 3 years, at which time the area must be assessed and submitted for re-designation HRSA currently implementing new designation application system and process Health and Wellness for all Arizonans

HPSA Score HRSA assigns each HPSA a score based on data we submit Max primary care score = 25 (Higher score = higher need) All clinics/providers in a HPSA have same HPSA score and identification number Primary care HPSA score based on 4 categories: Population to provider ratio % population with incomes below FPL Infant Health Index Travel distance/time to nearest source of accessible care outside of HPSA Health and Wellness for all Arizonans

Area vs. Facility HPSAs Area (geo or pop) HPSAs: Community-based (must follow AZ Primary Care Area boundaries) Must meet specific criteria regarding population-to-provider ratio Must eliminate all contiguous areas as potential sources of care Must be updated regularly Auto Facility HPSAs: Only applies to that facility (and satellites in the case of FQHCs) No ratio or contiguous area requirements for designation Currently no requirement to update (scores may be reassessed upon request) Health and Wellness for all Arizonans

HPSAs and Workforce Programs HPSA designation is an eligibility requirement for: National Health Service Corps (NHSC) Loan Repayment NHSC Scholar Program Arizona State Loan Repayment J-1 Visa Waiver Program May use area or facility HPSA score when applying for these programs use whichever is higher. Note that NHSC Freezes HPSA scores in their system on January 1 of each year (i.e. takes a snapshot of HPSAs on 1/1 and uses those throughout LRP cycle) Health and Wellness for all Arizonans

Rural Health Clinics RHCs are eligible for facility HPSA only if they provide access to care regardless of ability to pay (including sliding fee scale) To obtain facility HPSA, RHCs must submit a Certificate of Eligibility form to HRSA (contact Tracy Lenartz for electronic copy of form) Health and Wellness for all Arizonans

IHS/Tribal Facilities Automatic Native American Population HPSA designation for each facility ADHS collaborated with OSD/HRSA to re-score IHS and tribal facilities in 2010/2011 While scores are fairly recent, please do contact us if your facility has experienced a significant change (i.e. provider turn-over) that could impact your score. Health and Wellness for all Arizonans

FQHCs and FQHC-LA ADHS collaborated with OSD/HRSA to re-score FQHC and LA facilities in 2012/2013 and in process to reassess again now Significant increase in facility scores across the state resulted from this effort Goal: ensure scoring is consistent and fair across AZ, and competitive nationally for NHSC While scores are fairly recent, please do contact us if your facility has experienced a significant change (i.e. provider turn-over) that could impact your score. Health and Wellness for all Arizonans

Resources HSD Interactive web-based mapping tool ( Designation Mapper ) http://www.azdhs.gov/prevention/health-systems-development/shortagedesignation/designation-mapper/index.php HRSA Shortage Designation Branch http://www.hrsa.gov/shortage/ HPSA Searchable Database http://hpsafind.hrsa.gov/ Health and Wellness for all Arizonans

HPSA Find Website http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx To find area HPSAs To find facility HPSAs Health and Wellness for all Arizonans

Search by County http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx Will give all HPSAs in county, including facilities Tip: FQHCs are listed only by parent site and county that site is located in Health and Wellness for all Arizonans

Search by Address http://datawarehouse.hrsa.gov/geoadvisor/shortagedesignationadvisor.aspx Note that this will NOT give you Facility HPSAs only Area HPSAs Health and Wellness for all Arizonans

Address Search - Example Health and Wellness for all Arizonans

Contact Info Tracy Lenartz, MPH Health Planning Consultant-Designations Coordinator ADHS Bureau of Health Systems Development tracy.lenartz@azdhs.gov Health and Wellness for all Arizonans

Any Questions? Thank You Health and Wellness for all Arizonans

Recruitment & Retention Tools and Trainings Michelle Varcho, MBA Director of Operations, 3RNet STAR² Center Consultant

STAR² Center Solutions, Training, and Assistance for Recruitment and Retention www.chcworkforce.org

Partnership: PCAs, PCOs, BPHC

NOWOFFERING BUNDLES INSTRUCTIONS STAR: Center staff nave canpiled ResotI"Ce 81.Slcles. based m common r-ecruitment and retentionissues. Make a selection from ooe oc both of the drop-down menus and dick 'submit'to review the resources that are included in the categoriesyou selected.alternativelyyou can "'select All toview acompletelist of STAR2Center resoorces.. Select a Bundle belowto 1o"iew articles, toolss 'INE:bsites,events, and mujtimedia resources relatedtotheselected topic. Association 10' 1Clinicians for the Underserved

Current Resources Self Assessment Tool Key Informant Interviews Resource Center Best Practice Form Newsletter Data Profiles!

Health Center Recruitment and Retention Data Summary HOC5000000: GENERIC HEALTH CENTER, INC. I O MAIN ST I ANYTOWN, USA I Z.34S Descriptive Att ributes Health Center Recruitment and Retention Trend Summary (compared to prior year profile) HOCSOOOOOO: GENERIC HEA LTH CENTER, INC. 921 fqhc!jfltrlwl"ed 70% ltgnlre.j(lfeo No 'rot l t l insa. Mo Yei tlklilllon fqhc Medic.id Penetr.bon Totallowl 1%Med,c;aid POPinSA NO " Uflln d POp ======-o--,e-o_ '--u ::.. -<I 1: oo;-nc;:_:redby_pc_h 5 1 _,,,. 13 15],4)4 84. 9 --- - j '7.......... I :mu <t2:wi 2 l HH5CMO,OOPlla!nlent/C&Jrren!MOSuft '::t: J..!!._K_ NP,P,\CNMPlxnt/CunentStaff :r NHS<.MO,OOVDQl_!!g'_&_ncrtlMOSt ff ' )NH ( NP)>,l\ (NMn(}_/(ul'feritSt-.itl!i' llit.1(1of AV! Pirf pet Med FTE lo MGMAMll "" "" 6 NHSC D11!n11 t PbOffllent / O.urent Slaff m ;?l NHSC Dentnt V «/ Ci.nentStaff rrt It_NHSC Plyc;h,t.CSW Ple«menc / StoffFTE 91NHS(_ h,l(\w V.c.ilnqj Cunents FTE... t Foct (% B s.t Se<YKI nonei.h) II <t 'l'nta Pfof, lc-\1 a<i9'h n \ e WhalNow? flti.i!tw p1otilt 1nd no.:,anv blut 11,aed d1t1 l)olnu,s pottm ltl 1rHs 011nmat. Access the Profile Uw:GuJde end Det.e Point BundleIn the f ' more det1ilson specific d.eto pol nu.end what they motan. lle1,1!ew the blue flaued data pol.n u and tupplemenurv ma terlak with your workforce team ta unpac:k the numbers and Identify 1peclfit l uuh to IMprOYe your warlrforte ptm.. Contad $TAR C.entersta ff tofu rther discus$ your profile ind/a. sdiedulelmhnlca l AnJ t'ilnte. o lnfopchcworirforce.arg OI' l&44)acu HIR E SHr<h th, STAR2 Ctntu wtb5it, (www.dlcworkforu.of1 t for1ookand tr ininis ra l t d tovoursp,c:ific: wortdoroiuuas Association,o' 1Clinicians for the Underserved

10th 25th 50th 75th 90th Curve <=14 14 32 78 140 >=1316 753 1,117 >=4215 1,740 2,445 3,019 3,624 >=1.35 63% 82% 98% 117% <=0.14 or >=0.89 23% 37% 50% 6,5%

2016 Training Monthly Webinar Series Video Tutorials State & Regional Trainings Advisory Groups Hot Topics R&R Issues PCA Conferences PCAs, CHCs, Clinicians

Regional Training for the individual

Personalized Technical Assistance Phone Email On-Site

National Trends Demand Growing, Aging Population Primary Care Clinicians Supply

Arizona s Trends Growing Population Aging Population Workforce Shortage s

2050 10,820,900 2015 6,758,300 Arizona Department of Administration, Office of Employment & Population Statistics: https://population.az.gov/population-projections

http://www.azdhs.gov/plan/report/aging/aia-report-2012.pdf

http://www.graham-center.org/online/etc/medialib/graham/documents/toolsresources/arizonapdf.par.0001.file.dat/arizona_final.pdf

Arizona CHC Challenges Patient Need: Non- Medical Use of Pain Meds Staffing for Team Based Care Dentists

Data Concrete issues & solutions Context

Patients with Drug Dependence Training Clinician Resources Peer Support Systems Internal Review Practices Office Policies Partnerships Pain Management Centers Psych Consults

Staffing Structures Intentionality vs. Need Benefits vs. Care Gaps Utilize Existing Workforce

http://www.azdhs.gov/hsd/data/documents/maps/dentalhpsas.pdf

Next Steps Go Online Review Your Profile & User Guide Complete Self-Assessment Tool Call Us Schedule Call for Profile Review Request TA from Workforce Expert

Michelle Varcho 800-787-2512 varcho@3rnet.org STAR² Center 844-ACU-HIRE info@chcworkforce.org

Incentives for Provider Recruitment and Retention 2016 Arizona Recruitment and Retention Forum March 31, 2016 Ana Roscetti, MPH Workforce Section Manager Public Health Prevention Services Division of Public Health Services l Arizona Department of Health Services Health and Wellness for all Arizonans

Workforce Programs Objectives To improve the accessibility of health care for underserved areas and populations in Arizona To incentivize primary medical, dental, and mental health who agree to serve in medically underserved areas by providing loan repayment incentives or in-kind support To encourage retention of healthcare professionals in areas of need Health and Wellness for all Arizonans

Workforce Workforce Programs Programs Objectives National Health Service Corps (NHSC) Loan Repayment Program Arizona Loan Repayment Programs (SLRP) Public or Non-profit Rural, Private Practice J-1 Visa Waiver Program National Interest Waiver Program Nurse Corps Scholarship & Loan Repayment Program Health and Wellness for all Arizonans

Arizona Loan Repayment Programs Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Administered by the Arizona Department of Health Services (ADHS), Arizona Primary Care Office (PCO) Provides loan repayment in exchange for an initial two year commitment in a Health Professional Shortage Area (HPSA) or an Arizona Medically Underserved Area (AzMUA) of the State Available to providers employed by a public or private non-profit or rural private practices located in a HPSA or an AzMUA A.R.S. 36-2172 and A.R.S. 36-2174 are the statutes that govern the programs. Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Program Updates in 2015: Governor Doug Ducey signed Senate Bill 1194 into law on Feb. 24, 2015. This bill became effective July 3, 2015 Enhances SLRP through 3 key changes: Expands the eligible disciplines Enhances the award amounts Extends the years of participation The law requires the program to prioritize providers who are residents of Arizona, providers in rural areas and those in areas with high Health Professional Shortage Area (HPSA) scores in Arizona. The law provides eligibility for part-time providers and those providing services via telemedicine. The law provides for an exempt rulemaking until December 31, 2016. No additional appropriation resulting from the legislation. Program operates at a combined state/federal funding of $850,000 per year. Health and Wellness for all Arizonans

Enhanced Arizona Loan Repayment Programs - At-A-Glance Categories Program Before SB 1194 Enhanced Program Effective July 3, 2015 Eligible Disciplines Award Amounts Physicians (Family Medicine, Dentists, OB/GYN, Pediatrics, Internal Medicine) PA, NP, Nurse Midwives Up to $40,000/2 year commitment for physicians and dentists per state statute Physicians (Family Medicine, OB/GYN, Pediatrics, Internal Medicine, Geriatrics, Psychiatry), Dentists PA, NP, Nurse Midwives, Behavioral Health Providers, Pharmacists Up to $65,000/2 year commitment for physicians and dentists Up to $15,000/2 year commitment for Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives per state statute Up to $50,000/2 year commitment for advanced practice practitioners Priority consideration given to providers in rural underserved areas, high HPSA score areas, and those who are residents of Arizona. Service Years Capped to 4 years per state statute No cap as long as provider continues to have qualifying loans. Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Eligible disciplines: Key Requirements for Providers and Service Sites: Employed and serving in a public, private non-profit or rural private practice site Located in a federally designated HPSA or AzMUA (rural private providers) Serve everyone regardless of ability to pay or source of payment Accept AHCCCS and Medicare Accept qualifying health plan assignment (NEW) Implement a Sliding Fee Scale for uninured or low income persons at or below 200% of the Federal Poverty Level Guidelines Health and Wellness for all Arizonans

Arizona Loan Repayment Programs Program Priorities since SB 1194 Revise the program administrative rules Final draft rules posted for a 30 day public comment period from February 19, 2016 till March 22, 2016 Final draft rules effective April 1, 2016 Revise the program website including program marketing materials and application forms Ready to launch by April 1 st, 2016 Increase program funding to support recruitment and retention Request for supplemental funding from HRSA Identify funding partners Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Impact of SB1194 Received Inquiries from February thru Nov 2015 N = 155 6% 8% 18% Employer/Site Primary Care Dental Provider Mental Health Provider Pharmacists Other 15% 43% 10% Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Actual Applications Received (Historical and Current) 18 16 14 12 10 8 6 4 2 0 Applications Received by Submission Deadline SB 1194 Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) CONTRACTED PROVIDERS Discipline FY 2014 FY 2015 FY 2016 Physicians 10 19 23 Dentists 3 7 11 Physician Assistants 2 3 4 Nurse Practitioners 1 4 3 Nurse Midwives 1 1 0 Pharmacists N/A N/A 2 TOTAL CONTRACTED 14 34 43 Total Funding $744,900 $620,000 $1,045,800* Funding Utilization (%) 32% 61% 100% * FY 2016: Federal ($200,000) + EMS (650,000) + AMSLP (195,800) = $1,045,800 Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Programmatic Rules Changes Effective April 1, 2016 1. R9-15-201. Qualifying Loans and Restrictions 2. R9-15-202. Primary Care Provider and Service Site Requirements 3. R9-15-203. Initial Application 4. R9-15-204. Supplemental Initial Application 5. R9-15-205. Renewal Application 6. R9-15-205.01 Renewal Application Restrictions 7. R9-15-206. Time-Frames 8. R9-15-207. Primary Care Provider Health Service Priority 9. R9-15-208. Rural Private Primary Care Provider Health Service Priority 10. R9-15-209. Allocation of Loan Repayment Funds 11. R9-15-210. Verification of Primary Care Services and Disbursement of Loan Repayment Funds 12. R9-15-211. Request for Change 13. R9-15-212. Contract Suspension 14. R9-15-213. Liquidated Damages for Failure to Complete the Terms of the Contract 15. R9-15-214. Waiver of Liquidated Damages 16. R9-15-215. Contract Cancellation Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-207. Primary Care Provider Health Service Priority (New Prioritization) Requires the determination of health service priority for each new or renewal application. Clarifies the health service priority scoring method for providers working at multiple sites: Uses the health service priority score of the primary site. Primary site is defined as the service site where the provider spends more than half of his full-time or half-time hours. If there is not a primary site, use the average of the total health service priority score for each site. Provides the scoring factors to use when determining the applicant s health service priority score. Clarifies the highest HPSA to use for a specific provider type Provides the method for breaking a tie when more than 1 provider have the same health service priority score and: Only one provider from the same service site or employer can be awarded due to the award cap per year; or Only one provider can be awarded due to funding limitation; Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) Current Prioritization Methodology (Maximum Points = 26) 1. Location of service site Rural = 4 Non Rural = 0 2. Degree of Shortage Ranking DOS 1 = 4 DOS 2 = 3 DOS 3 = 2 DOS 4 = 1 3. Population to Provider Ratio Points 0 to 10 points 4. Percentage of minority populations in the primary care area >50% = 4 40-50% = 3 30-39% = 2 20-29% = 1 <20% = 0 5. Distance of the site to next nearest town with a population of 20,000 or greater >45 miles = 4 <45 miles = 0 Priority 1 = 18-26 points (100% funding) Priority 2 = 9-17 points (90% funding) Priority 3 = 0-8 points (80% funding) Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-207. Primary Care Provider Health Service Priority (New Prioritization) Maximum Points = 71 The total health service priority score will be obtained for each new or renewal application based on points obtained from the following factors: 1. Whether the service site is located in a rural area Yes = 10 points No = 0 points 2. Service site s highest HPSA score as applicable to the applicant s discipline 3. Percentage of the service site s total patient encounters that are underserved (total of encounters on Medicaid (AHCCCS), Medicare, Sliding Fee Scale, or free of charge) Greater than 50% = 10 points 35-50% = 8 points 26-34% = 6 points 11-25% = 4 points Less than 10% = 2 points 4. Whether the distance of the service site to the next nearest Sliding Fee Scale clinic providing similar type service as the applicant is greater than or equal to 25 miles Greater than 25 miles = 4 points Less than 25 miles = 0 Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-207. Primary Care Provider Health Service Priority (New Prioritization) 5. For the initial application, whether the applicant is newly employed at the service site or by the employer (Newly employed as defined in A.A.C. R9-15-201) Yes = 2 points No = 0 points 6. Whether the applicant is providing services with a patient on-site Yes = 4 points No = 0 points 7. Whether the applicant is a resident of Arizona per A.R.S. 15-1802 (hyperlink to http://www.azleg.gov/ars/15/01802.htm) Yes = 4 points No = 0 points 8. Whether the applicant is a graduate of an Arizona graduate educational institution Yes = 4 points No = 0 points 9. Whether the applicant has experience in serving the medically underserved as defined in A.A.C. R9-15-201) Yes = 4 points No = 0 points 10. Whether the applicant is providing services full-time or half-time Yes = 3 points No = 0 points Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-209. Allocation of Loan Repayment Funds Allocation of funds for approved new or renewal applications will be based on descending health service priority score. Award amounts are based on the service site s HPSA score. Order of allocation: 1. 3 rd year renewals in HPSA 14 and above (April allocation process); 2. Initial applications (June allocation process); New initial application awards are capped to 2 per site per year to a total maximum of 4 per employer per year. 3. Other renewals (October allocation process) Initial applications denied during the calendar year due to the annual award cap per site or per employer Previously denied application Renewals after 3 rd year regardless of HPSA Renewals after the initial contract for those in HPSA below 14 Resuming participation after a contract lapse. Approved renewals with a period lapse will be allocated an amount for the contract year succeeding the last participation year. Provides the policy for donated funds and the Department s process for administering donated funds Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-209. Allocation of Loan Repayment Funds Payment Structure for Physicians and Dentists Contract Year of Service Maximum Annual Amount for Full-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $65,000 $58,500 $52,000 Third year $35,000 $31,500 $28,000 Fourth year $25,000 $22,500 $20,000 Fifth year and continuing $15,000 $13,500 $12,000 Contract Year of Service Maximum Annual Amount for Part-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $32,500 $29,250 $26,000 Third year $17,500 $15,750 $14,000 Fourth year $12,500 $11,250 $10,000 Fifth year and continuing $7,500 $6,750 $6,000 Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) R9-15-209. Allocation of Loan Repayment Funds Payment Structure for Other Provider Types Maximum Annual Amount for Full-Time Contract Year of Service Advance Practice Providers, Behavioral Health Providers and Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $50,000 $45,000 $40,000 Third year $25,000 $22,500 $20,000 Fourth year $20,000 $18,000 $16,000 Fifth year and continuing $10,000 $9,000 $8,000 Maximum Annual Amount for Part -Time Contract Year of Service Advance Practice Providers, Behavioral Health Providers and Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $25,000 $22,500 $20,000 Third year $12,500 $11,250 $10,000 Fourth year $10,000 $9,000 $8,000 Fifth year and continuing $5,000 $4,500 $4,000 Health and Wellness for all Arizonans

Arizona State Loan Repayment Programs (SLRP) EXAMPLE Health Service Priority Points Applicant Ranking HPSA Score Discipline Amount Eligible* 70 1 16 MD $58,500 69 2 21 DDS $65,000 67 3 14 NP $45,000 63 4 18 PA $50,000 60 5 20 MD $65,000 58 6 15 MD $58,500 55 7 21 NP $50,000 54 8 16 PharmD $45,000 53 9 18 LCSW $50,000 52 10 21 DDS $65,000 52 10 21 Pharm D $50,000 * Or up to the applicant s total student loan indebtedness Health and Wellness for all Arizonans

For more information Arizona State Loan Repayment Programs http://www.azdhs.gov/hsd/az_loan_repayment.htm. Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program (NHSC LRP) An opportunity to pay off student loans while providing care to communities in need Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program (NHSC LRP) An opportunity to pay off student loans while providing care to communities in need Health and Wellness for all Arizonans

Bureau of clinician recruitment and service The NHSC is part of HRSA s Bureau of Clinician Recruitment and Service (BCRS) BCRS coordinates the recruitment and retention of health professionals to work in medically underserved communities Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Bureau of Clinician Recruitment and Service (BCRS) Health and Wellness for all Arizonans

NURSE Corps Scholarship Program NCSP BCRS chart NHHSP Native Hawaiian Health Scholarship Program NHSC SP National Health Service Corps Scholarship Program NURSE Corp Loan Repayment Program NCLRP BHW NHSC LRP National Health Service Corps Loan Repayment Program Faculty Loan Repayment Program FLRP NHSC SLRP State Loan Repayment Program NHSC S2S National Health Service Corps Student to Service Loan Repayment Pilot Program Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program Recruits fully-trained health professionals to provide culturally competent, interdisciplinary primary health care services to underserved populations located in selected Health Professional Shortage Areas (HPSAs) Assists clinicians in repayment of qualifying educational loans that are still owed in exchange for service in a HPSA Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program Key Updates ACA-related funding for NHSC expired on Sept. 30, 2015. NHSC funding reverts back to base funding. In FY 2014, Arizona received 5 th highest allocation for NHSC LRP funding at $6.84 million (NY, CA, IL, MO, AZ). New awards - $5.48 Million 59% approval rate for new applications 67% approval rate for new applications at HPSA score 14 and above. Continuation - $1.36 Million 100% approval rate for continuation applications. Total NHSC LRP participants in AZ: 379 Total NHSC certified sites in AZ: 971 Health and Wellness for all Arizonans

National Health Service Corps (NHSC) Loan Repayment NHSC Field Strength - National Data 28% Mental Health Providers 26% Physicians 2% Dental Hygienists Dentists 12% Nurse Practitioners 18% Physician Assistants 12% Nurse Midwives 2% More than 9,200 NHSC primary care providers serving at nearly 5,000 sites. Health and Wellness for all Arizonans

National Health Service Corps (NHSC) Loan Repayment Arizona - Field Strength Report 2015 N = 379 CNM, 3% PA, 9% Mental, 17% MD/DO, 33% NP, 26% Dentist, 13% RDH, 2% Health and Wellness for all Arizonans

National Health Service Corps (NHSC) Loan Repayment Provider Eligibility ELIGIBLE DISCIPLINES Must be licensed in one of the following: Physician (MD or DO) Nurse practitioner Certified nurse-midwife Physician assistant Dentist (general or pediatric) Dental hygienist Psychiatrist Licensed clinical psychologist Licensed clinical social worker Psychiatric nurse specialist Marriage and family therapist Licensed professional counselor Must meet the following requirements: US Citizen or National Current AZ license Have unpaid government or commercial loans for school tuition, reasonable educational and living expenses, segregated from all other debts (that is, not consolidated with non-educational loans) Currently work or ready to work in a NHSCapproved facility located in a Health Professional Shortage Area Health and Wellness for all Arizonans

National Health Service Corps (NHSC) Loan Repayment How do providers benefit from NHSC LRP? Service By joining the thousands of NHSC participants across the country, you have an opportunity to provide primary health care services to communities in need Eligible Service: Part Time or Full-Time, Primary Care Outpatient Services, Inpatient Services at Critical Access Hospitals, Telemedicine, Teaching, Minimal Administrative Ineligible Service: Inpatient Services except CAH, Home Health Loan Repayment Funds to repay outstanding qualifying educational loans Funds are exempt from federal income and employment taxes Funds are not included as wages when determining Social Security benefits An opportunity to be part of something bigger than yourself Health and Wellness for all Arizonans

Program options: National Health Service Corps (NHSC) Loan Repayment How do providers benefit from NHSC LRP? Full time: 40 hours per week for a minimum of 45 weeks per year Part time: 20 hours per for a minimum of 45 weeks per year Additional Loan Repayment Awards: Continue loan repayment beyond the initial contract, one year at a time, and pay off all qualifying educational loans Health and Wellness for all Arizonans

National Health Service Corps (NHSC) Loan Repayment Service Site Eligibility Eligible Sites Must meet the following eligibility requirements: Government/Public, Private Non-Profit, IHS/Tribal, Public Health Department, Private Practice, Hospital- Affiliated Clinics, Critical Access Hospitals Federally Qualified Health Center or Look-Alike (FQHC or FQHC-LA) Certified Rural Health Clinic (RHC) Indian Health Service Site (Federal or Tribal) Solo or Group Partnership or Practice Hospital-Affiliated Primary Care Practice Critical Access Hospital Managed Care Network State or Federal Prison U.S. Immigration, Customs and Enforcement Site Public Health Department Other Health Clinics Located in a designated HPSA Accept Medicare and Medicaid Use Sliding Fee Scale Non-discriminatory policy in the provision of health services Has capacity to maintain a competitive salary, benefits, and malpractice coverage package for clinicians Must receive NHSC certification Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program Key Updates Application cycle is open for NHSC Loan Repayment Program through April 5, 2016 7:30 pm ET. NHSC Site Application Cycle is set to open on April 12, 2016. Total NHSC participants in AZ: 351 LRP: 328 SP: 22 S2S: 1 Total unique NHSC certified sites in AZ (March 2016): 430 Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program Other Updates HPSA score effective January 1, 2016 will be used for the prioritization funding. Providers in residency programs with a provisional license may apply; however, they must possess a current, full, permanent, unencumbered, unrestricted health professional license before accepting an NHSC LRP award. Behavioral & Mental Health Providers: At least 32 hours/week or the full-time hours must be spent for providing patient care at the approved service site(s) previously 21 hours of the 40 hours per week. Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program Other Updates - Continuation Primary Care Behavioral and Mental Health providers must practice in a community based setting that provides access to comprehensive mental and behavioral health services. Participants who are providing services in a private practice (either solo or group practice) will only be allowed to fulfill their NHSC service obligation if it can be demonstrated that the practice is formally affiliated with a comprehensive community based facility. Definition: Comprehensive Community Based Primary Behavioral and Mental Health Setting or Facility- For the purposes of the National Health Service Corps, this is a site that provides comprehensive primary behavioral and mental health care services, which may include but is not limited to: screening and assessment, diagnosis, treatment plans, therapeutic services including access to medication prescribing and management, crisis care including 24 hour call access, consultative services, care coordination, and case management. Sites must function as part of a system of care to ensure continuity of patient-centered, comprehensive, and coordinated care. The site must offer or ensure access to ancillary, inpatient, and specialty referrals. Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program NHSC Site Certification Process NHSC Site Application Cycle set to open on 4/12/16 Sign up to receive notice: https://public.govdelivery.com/accounts/ushhshrsa/subscriber/new?topic_id=ushhshrsa_134 Review the NHSC Site Reference Guide http://nhsc.hrsa.gov/downloads/sitereference.pdf Prepare supporting documents Policies on Non-Discrimination of patients based upon race, color, sex, national origin, disability, religion, age, or sexual orientation Sliding Fee Schedule (SFS) Documents SFS Table based on current Federal Poverty Level Guidelines SFS Policies and Procedures SFS Financial Assistance Worksheet SFS Signage Proof of Referral to Ancillary, Inpatient and Specialty Care NHSC Site Data Table (12 month data required) Apply online and apply early Health and Wellness for all Arizonans

National Health Service Corps Loan Repayment Program NHSC Job Center Health and Wellness for all Arizonans

Learn more at http://www.nhsc.hrsa.gov/loanrepayment/index.html Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Program Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Program Administered by the Bureau of Healthcare Workforce (BHW) in the Health Resources Services Administration (HRSA) of the US Department of Health and Human Services (DHHS). Aims to alleviate the shortage of nurses across the country by offering loan repayment assistance to registered nurses and advanced practice registered nurses, such as nurse practitioners, working in a public or private nonprofit Critical Shortage Facility OR nurse faculty employed by an accredited school of nursing. Critical Shortage Facility - a health care facility located in, designated as, or serving a primary medical care or mental Health Professional Shortage Area (HPSA). Repayment of 60 percent of the total outstanding qualifying educational loan balance incurred while pursuing an education in nursing in exchange for a 2-year service commitment. Qualifying participants may receive an additional 25 percent of their original loan balance for a third year of service. Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Program Eligibility Requirements: RNs or Advanced Practice Registered Nurses i.e. Nurse Practitioners U.S. citizen, U.S. national, or lawful permanent resident Current license to practice as an RN and received a diploma, associate s, bachelor s, master s, or doctoral degree in nursing Full time employment (at least 32 hours per week) at a public or private nonprofit Critical Shortage Facility OR employed full time at an accredited, public or private nonprofit school of nursing; Completed the education program for which the loan applies. Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Program Service Site Eligibility Requirements: Nurse Faculty: Accredited, public or private nonprofit school of nursing Registered Nurses and Advanced Practice Registered Nurses: Public or private nonprofit Critical Shortage Facility: Critical Access Hospital Disproportionate Share Hospital Public Hospital Federally Qualified Health Center Indian Health Service Health Center Native Hawaiian Health Center Rural Health Clinic Skilled Nursing Facility State or Local Public Health or Human Services Department Ambulatory Surgical Center Home Health Agency Hospice Program Non-Disproportionate Share Hospital Nursing Home Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Program Funding Preference: Registered Nurses and Advanced Practice Registered Nurses: Nurses with the greatest financial need (those with debt to salary ratio of 20 percent or greater) Mental Health or Primary Care Health Professional Shortage Area (HPSA) score. Nurse Faculty: Nurse faculty with the greatest financial need (with debt to salary ratio of 20 percent or greater) Working at schools of nursing with at least 50 percent enrollment of students from a disadvantaged background. Health and Wellness for all Arizonans

Nurse Corps Loan Repayment Programs (ALRP) Funding Tier Refactoring RNs & APRNs Nurse Faculty Funding Preference Tier Debt to Salary Ratio CSF Primary Care or Mental Health HPSA Score Debt to Salary Ratio Schools of Nursing (SON) Funding Preference Tiers Tier 1 100% 14 Tier 2 <100% 14 Tier 3 100% 13 Tier 4 <100% 13 100% <100% SON with at least 50 percent of students from a disadvantage background Tier 1 All other SON Tier 2 SON with at least 50 percent of students from a disadvantage background Tier 3 All other Tier 4 Health and Wellness for all Arizonans

For more information Nurse Corps Loan Repayment Program: http://www.hrsa.gov/loanscholarships/repayment/nursing/index.html Health and Wellness for all Arizonans

Arizona J1 Visa Waiver Program Health and Wellness for all Arizonans

Arizona J1 Visa Waiver Program What is a J1 Visa? Temporary, Nonimmigrant Visa Clinical Resident or Fellow Duration limit of seven years Limited exclusively to Graduate Medical Education (i.e., no moonlighting) Mandatory, across-the-board, two-year home residence obligation When to employ a J1 physician? The J1 Visa Waiver Program is a last resort recruitment strategy if the employer has a significant challenge in recruiting and can demonstrate unsuccessful recruitment efforts of US-based physicians for at least 6 months or longer Health and Wellness for all Arizonans

Arizona J1 Visa Waiver Program RELEVANCE OF TWO-YEAR HOME RESIDENCE OBLIGATION: Disqualifies J-1 from H-1B visa and/or permanent residence status unless: Obtains a waiver of obligation; or Goes back to HOME country for two years J-1 WAIVER OPTIONS: Interested Governmental Agency (IGA) State Department of Health Exceptional Hardship Persecution Health and Wellness for all Arizonans

Arizona J1 Visa Waiver Program J1 Visa Waiver - a waiver of the two-year foreign residence requirement as it applies to foreign medical graduates (pursuant to Section 214(k) of the Immigration and Nationality Act 8 USC 1184, as amended by PL 103-416). The J1 Visa Waiver Program (aka Conrad State 30 Program) was created in 1994 to help rural and underserved communities across the United States in recruiting primary care providers. The J1 Visa Waiver Program allows foreign physicians to practice in medically-underserved communities without returning to their home residence, thus, allowing them to receive nonimmigrant, H-1B status (temporary worker in specialty occupation) for three years. The U.S. Citizenship and Immigration Services (USCIS) is the Federal Agency that grants J1 Visa Waivers. The Arizona Department of Health Services (ADHS) acts as an Interested Agency in supporting J1 Visa Waiver requests on behalf of J1 physicians willing to practice in medically underserved areas of the State. Thirty (30) slots are available per year (22 primary care, 7 specialist, 1 discretionary). Annual application cycle is from October 1 through November 30. Health and Wellness for all Arizonans

Arizona J1 Visa Waiver Program Eligible disciplines: MDs in primary care discipline (internal medicine, family or general practice, pediatrics, OB/GYN or psychiatry) or specialists Provider Have an offer of full time employment for 40 hours per week at an eligible service site 3 year minimum obligation Provide primary care or specialty services in an approved site AZ medical license or eligible for an AZ medical license Service Site Located in a designated HPSA, MUA or MUP Accept Medicare and Medicaid Have a non-discriminatory policy in the provision of health services Use a Sliding Fee Scale Demonstrate unsuccessful recruitment efforts of a U.S. citizen physician for at least 6 months prior to the J1 waiver request Operational and providing care for at least six months as of the date of the request Health and Wellness for all Arizonans

Arizona National Interest Waiver Program (NIW) The Federal National Interest Waiver (NIW) program allows certain foreign workers including foreign physicians (MDs) with advanced degrees or exceptional abilities to work in the United States. The federal guidelines allow states to recommend a national interest waiver to foreign physicians. ADHS act as an interested agency attesting that the foreign physician s work is in the public interest. ADHS will consider requests for ADHS NIW support from J1 physicians meeting the following conditions: Obtained a J1 waiver from USCIS based on ADHS recommendation Practiced at an eligible service site (within designated HPSA/MUA) for at least one year immediately preceding the request for an ADHS NIW support and will continue to practice in the same or similar setting to a total aggregate of 5 years (including J1 obligation) Complied with the ADHS J-1 Visa Waiver Programs policies Health and Wellness for all Arizonans

For more information Arizona J1 Visa Waiver Program http://www.azdhs.gov/hsd/workforce/j-1-waiver/index.htm Arizona National Interest Waiver Program http://www.azdhs.gov/hsd/workforce/national-interest-waiver.htm Health and Wellness for all Arizonans

REGISTER YOUR FACILITY NOW! www.3rnet.org Health and Wellness for all Arizonans

AZ 3RNet Program Contacts AZ 3RNet Program Contacts Center for Rural Health, www.crh.arizona.edu Joyce Hospodar, MBA, MPA, Manager Health Systems Development hospodar@email.arizona.edu, 520.626.2432 Rebecca Ruiz, Senior Program Coordinator raruiz@email.arizona.edu, 520. 626.2243 ADHS, Bureau of Health Systems Development, www.azdhs.gov/hsd/ Ana Lyn Roscetti, MPH, Workforce Section Manager ana.lyn.roscetti@azdhs.gov, 602.542.1066 Arizona Alliance for Community Health Centers, www.aachc/org Lourdes Paez, Workforce Development Programs lourdesp@aachc.org, 602.288.7550 Health and Wellness for all Arizonans 56

ARIZONA PRIMARY OFFICE CONTACT INFORMATION Patricia Tarango, Bureau Chief, Health Systems Development Email: Patricia.Tarango@azdhs.gov Phone: (602) 542-1436 Ana Lyn Roscetti, Workforce Section Manager Email: ana.lyn.roscetti@azdhs.gov Phone: (602) 542-1066 Tracy Lenartz, Designations Specialist/Health Planning Consultant Email: Tracy.Lenartz@azdhs.gov Phone: (602) 542-1772 Health and Wellness for all Arizonans

Health and Wellness for all Arizonans

North Country HealthCare/ NAHEC Family Medicine Residency Program Presentation to the 2016 Recruitment and Retention Conference March 31, 2016

Presentation Overview North Country/ NAHEC Overview Overview of need Graduate Medical Education 101 NC/NAHEC Family Medicine Residency Program Why Teaching Health Centers

North Country History and Mission Northern Arizona AHEC- 1987 Flagstaff Community Free Clinic- 1991 North Country HealthCare (FQHC)- 1996 To provide accessible, affordable, comprehensive, quality primary healthcare in an atmosphere of respect, dignity and cultural sensitivity. The health and well-being of patients and community alike are promoted through direct services, training / education, outreach and advocacy.

North Country Services Clinical Primary Care Medical Services (FM, IM,OB/Gyn, Peds) Dental Behavioral Health Prenatal Care Breast & Cervical Cancer Screening Diabetes Management Program Integrative Medicine Pharmacy HIV/AIDS HCV (Hepatitis C) Community Health Health Benefits O&E Well Woman & Fit At Fifty Health Check Programs Prenatal & Well Child Programs Diabetes Management RESEP HIV/AIDS Program NACASA Hermosa Vida Educational Youth Academic Preparedness, College Readiness, and Health Professions exploration Health Professions Student Education and Training Medical Education Health Professional Continuing Education Programs Community Health Education Research

North Country HealthCare Service Area Sites