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West Virginia’s Primary Primary
Care Workforce Pipeline T i i Training Programs
Presented to “Presented to “Strengthening the Health Care Safety-Net Workforce Though Cooperation, Planning, and Policy”
July 20, 2009NACHC-NCSL-ASTHO-NASHP
Convention CenterPhiladelphia, PA
Hilda R. Heady, MSWHilda R. Heady, MSWAssociate Vice President for Rural HealthAssociate Vice President for Rural HealthRobert C. Byrd Health Sciences Center of Robert C. Byrd Health Sciences Center of
West Virginia UniversityWest Virginia UniversityExecutive Director WV Rural Health EducationExecutive Director WV Rural Health Education
Partnerships/AHECPartnerships/AHEC
2
The MessageThe Message
State policymakers, educational State policymakers, educational institutions, and community leaders institutions, and community leaders working as a partnership team can make working as a partnership team can make a difference.a difference.
There is no ONE silver bullet, therefore There is no ONE silver bullet, therefore strategies appropriate for states and strategies appropriate for states and regions must be blended into a full regions must be blended into a full pipeline of programspipeline of programspipeline of programs.pipeline of programs.
Outcomes should be directly linked to Outcomes should be directly linked to health status, program elements, and health status, program elements, and best practices.best practices.
Synergy and Success requireSynergy and Success require
VisionVision
LeadershipLeadership
The social and political The social and political will to do the right thingwill to do the right thing
3
Experience and EvidenceExperience and EvidenceRural Training Tracks for professional Rural Training Tracks for professional students and graduate residentsstudents and graduate residents
Significant portion of training in rural Significant portion of training in rural communitiescommunities
Financial incentives in training with or Financial incentives in training with or without service obligations without service obligations
Experience and Evidence supportsExperience and Evidence supportsEducational Strategies that work:Educational Strategies that work:
Pipeline programs ith r ral foc s and Pipeline programs ith r ral foc s and Pipeline programs with rural focus and Pipeline programs with rural focus and contentcontent
Recruiting rural people into programsRecruiting rural people into programs
Strategic admissions’ strategies (% of Strategic admissions’ strategies (% of class, reserved slots, rural preferences)class, reserved slots, rural preferences)
4
Experience and EvidenceExperience and Evidence
Community lead initiativesCommunity lead initiativesFi i l i ti f d t Fi i l i ti f d t •• Financial incentives from and to Financial incentives from and to CommunitiesCommunities
•• Focus on health status of communitiesFocus on health status of communities•• Strategies that improve community’s Strategies that improve community’s
ability to recruit and retain healthcare ability to recruit and retain healthcare ability to recruit and retain healthcare ability to recruit and retain healthcare providersproviders
•• Community economic developmentCommunity economic development
Rural and UnderservedRural and UnderservedHealth Professions Workforce Health Professions Workforce
DevelopmentDevelopment
Know the principles and strategies Know the principles and strategies and piece them togetherand piece them together
TrainPay
SupportRecruit Rural
them
y
do it!
Learners
Require
5
Th W VTh W VThe West Virginia The West Virginia ExperienceExperience
HistoryHistory
Election of an “education” Governor Election of an “education” Governor 19881988Medical Schools War of 1991Medical Schools War of 1991ed ca Sc oo s a o 99ed ca Sc oo s a o 99Passage and reauthorization of Passage and reauthorization of legislation 1991, 1995, 1998, 2001, legislation 1991, 1995, 1998, 2001, 20062006W.K. Kellogg CPI grant 1992W.K. Kellogg CPI grant 1992--19961996Rural Health Advisory Panel Rural Health Advisory Panel R&R committee 1998R&R committee 1998AHEC grant 2002AHEC grant 2002
6
WV LegislationWV LegislationRural Health Initiative Act HB 213 Rural Health Initiative Act HB 213 Oct. 18, 1991 (code reference: Oct. 18, 1991 (code reference: §§18B18B--1616--1)1)•• Established 16 performance goalsEstablished 16 performance goals•• Established powers and duties of Vice Established powers and duties of Vice
Chancellor for Health SciencesChancellor for Health Sciences•• Created State Rural Health Advisory Created State Rural Health Advisory Created State Rural Health Advisory Created State Rural Health Advisory
PanelPanel•• Establishment and operations of Establishment and operations of
primary care training sitesprimary care training sites•• Allocation of appropriationsAllocation of appropriations
WV Legislation con’tWV Legislation con’tRecruitment and Retention Committee Recruitment and Retention Committee
placed in code in 1998 placed in code in 1998 §§18B18B--1616--6(f):6(f):placed in code in 1998 placed in code in 1998 §§18B18B 1616 6(f):6(f):
Duties: facilitate statewide and Duties: facilitate statewide and interagency coordination around R&R interagency coordination around R&R need and financial incentivesneed and financial incentives
Links health care and economic Links health care and economic Links health care and economic Links health care and economic development agencies around R&Rdevelopment agencies around R&R
Reports annually to legislatureReports annually to legislature
7
West Virginia
EDUCATIONAL PIPELINEPublic School
7-12 GradeCollege Postgraduate Community
PracticeProfessional Education
Financial Incentive HSSP MSLF
K-12 Programs
Rural Preceptors & Academic AffiliationsWVRHEP
WVAHECRural Rotations C i
and Assistance Programs
SLRPRRCP
HSSP, MSLFSEARCH
Rural Scholars
Rural Rotations
HCOPCommunity Based
Strategies
2008 WVRHEP/AHEC Infrastructure2008 WVRHEP/AHEC Infrastructure
533 training sites in 55 counties533 training sites in 55 counties
800 li i l fi ld f l800 li i l fi ld f l800 clinical field faculty800 clinical field faculty
8 regional consortia with local boards 8 regional consortia with local boards and 4 AHEC Centers with local/campus and 4 AHEC Centers with local/campus boardsboards
15 site coordinators, 5 AHEC center 15 site coordinators, 5 AHEC center directors, program and support staff directors, program and support staff
17 Learning Resource Centers17 Learning Resource Centers
8
Types of Training SitesTypes of Training Sites
•• CHCsCHCs•• FQHCs FQHCs QQ•• RHCsRHCs•• Small rural hospitals & CAHsSmall rural hospitals & CAHs•• Dental officesDental offices•• PharmaciesPharmacies•• Home health agenciesHome health agenciesHome health agenciesHome health agencies•• Schools and school based clinicsSchools and school based clinics•• Etc.Etc.
WVRHEP/AHEC InfrastructureWVRHEP/AHEC Infrastructure
100 student rotations per month100 student rotations per monthSt t l l R l H lth Ad i St t l l R l H lth Ad i State level Rural Health Advisory State level Rural Health Advisory Panel specified in legislation Panel specified in legislation serves both state and federal serves both state and federal functionsfunctions$2.4 million per year to $2.4 million per year to
iti $4 illi t iti $4 illi t communities, $4 million to communities, $4 million to schools for rural health trainingschools for rural health training$100K per AHEC center in federal $100K per AHEC center in federal fundingfunding
9
Outcomes of WV’s Outcomes of WV’s Pipeline Partnership Pipeline Partnership
Programs Programs
HSTA OutcomesHSTA Outcomes95% enter college vs. 56% 95% enter college vs. 56% for all WVfor all WV
59% in health career majors 59% in health career majors VS 17% for all WVVS 17% for all WV
786 (80%) of the 982 HSTA 786 (80%) of the 982 HSTA graduates are still in collegegraduates are still in college
10
HSTA OutcomesHSTA Outcomes
55 HSTA Scholars in 55 HSTA Scholars in graduate/prof schoolgraduate/prof schoolgraduate/prof schoolgraduate/prof school
27 HSTA Scholars in health 27 HSTA Scholars in health sciencessciences
10 HSTA graduates currently 10 HSTA graduates currently in medical schoolin medical school
Discipline Number in Rural Practice
Number w Fin. Incentives
Physicians (1991-2005 graduates) 289 101 (35%)
Nurse Practitioners/Nurse Educators 106 49 (46%)
Nurse-Midwife 1 ·
Physician Assistants 181 50 (28%)Physician Assistants 181 50 (28%)
Nurses 89 ·
Dentists 111 2 (2%)
Dental Hygienists 26 ·
Pharmacists 199 ·
Physical Therapists 59 3 (5%)
Occupational Therapists 59 3 (5%)
Medical Technologists 8 ·
Masters in Public Health 1 ·
Social Worker 1 ·
TOTAL 1072 205 (19%)
11
Physician R&R 1999 to 2008Physician R&R 1999 to 2008Number of physicians who did RHEP rural Number of physicians who did RHEP rural rotations and are currently practicing in rural rotations and are currently practicing in rural areas has increased steadily from 88 to 289.areas has increased steadily from 88 to 289.
The rural practice site of each DO & MD The rural practice site of each DO & MD graduate is regraduate is re--verified annually so the count verified annually so the count each year reflects the loss of some rural each year reflects the loss of some rural practitioners to urban and outpractitioners to urban and out--ofof--state state practice. practice.
Despite this expected loss, the number of Despite this expected loss, the number of medical graduates in rural practice has medical graduates in rural practice has increased dramatically in the past 10 years at increased dramatically in the past 10 years at an average annual rate of 14.1%.an average annual rate of 14.1%.
Physicians with RHEP Rotations Practicing in Rural Ares of West Virginia, 1999-2008
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R&R Committee of RHEP/AHEC coordinates R&R Committee of RHEP/AHEC coordinates Five State/Federal Incentive ProgramsFive State/Federal Incentive Programs
•Target financial incentives to students and physician residents
•Combine incentive with rural training (i.e. complete special community based projects, research, etc.)
• Package multiple programs for highly promising candidatespromising candidates
•The National Health Service Corps (NHSC) Loan Repayment Program as the Bureau for Public Health assists physicians in applying to this program.
Recruitment Incentives for Rural PracticeRecruitment Incentives for Rural Practice
West Virginia Higher Education Policy CommissionHealth Sciences Scholarship Program 93
WV Rural Health Education PartnershipsSEARCH Training Stipends 43Community Scholarship Program 7
Bureau for Public Health, Division of Rural Health & RecruitmentRecruitment & Retention Community Project 92
St t L R t P 30State Loan Repayment Program 30
NHSC Loan Repayment Program 13
TOTAL 278 Awards
13
RETENTION RETENTION Medical School Graduates from 1998Medical School Graduates from 1998--
2003 Practicing in West Virginia2003 Practicing in West Virginia
Of 1,141 graduates of the state’s Of 1,141 graduates of the state’s three medical schools three medical schools
38% are practicing in West Virginia.38% are practicing in West Virginia.
9.5% are practicing in rural areas.9.5% are practicing in rural areas.
Graduates with Completed Training, 1998-2003
# Primary
InstitutionsTotalGraduates
Total# WV
yCare in WV # Rural
West Virginia University 514 481 176 (36.6%) 95 (19.8%) 34 (7.1%)Marshall University 289 273 112 (41.0%) 68 (24.9%) 20 (7.3%)WV School of
Osteopathic Medicine387 387 143 (37.0%) 109 (28.2%) 54 (14.0%)
TOTAL 1,190 1,141 431 (37.8%) 272 (23.8%) 108 (9.5%)
14
OutcomesOutcomes
State has eliminated 8 HPSA State has eliminated 8 HPSA ti i 10 91 h lth ti i 10 91 h lth counties in 10 years; 91 health counties in 10 years; 91 health
professionals in these counties professionals in these counties completed required rural rotations completed required rural rotations
In 10 years rural physicians who In 10 years rural physicians who In 10 years rural physicians who In 10 years rural physicians who complete this training increased by complete this training increased by 228%, annual rate of 14%228%, annual rate of 14%
OutcomesOutcomesWV Schools of Medicine consistently WV Schools of Medicine consistently
ranked above national averagesranked above national averages
•• US News and World Reports Best US News and World Reports Best Graduate SchoolsGraduate Schools
•• AAMC and AACOM master file dataAAMC and AACOM master file data
•• AAFP for 3 years at or above 15% of AAFP for 3 years at or above 15% of graduates who go into primary caregraduates who go into primary care
15
Practice Location 7 to 10 years after Practice Location 7 to 10 years after Graduation and Medical School Graduation and Medical School
Attended by WV Physician Attended by WV Physician Workforce 1981 to 2006Workforce 1981 to 2006
Study commissioned by WV HEPC to Study commissioned by WV HEPC to Cecil B. Sheps Center, UNC, Cecil B. Sheps Center, UNC,
hhDon Pathman, MD, MPHDon Pathman, MD, MPH
Pathman Report Findings, con’tPathman Report Findings, con’t"From 1981 to 2006 the number of "From 1981 to 2006 the number of physicians in rural West Virginia physicians in rural West Virginia increased by 52%, from 881 to increased by 52%, from 881 to increased by 52%, from 881 to increased by 52%, from 881 to 1,339." (Even with this increase, WV 1,339." (Even with this increase, WV primary care workforce remained primary care workforce remained stable) stable)
Pathman attributes this to "increase Pathman attributes this to "increase Pathman attributes this to increase Pathman attributes this to increase in number of practicing graduates in number of practicing graduates from WV's schools . . .“from WV's schools . . .“
16
Location of Physicians (Location of Physicians (Primary CarePrimary Care and and NonNon--Primary Primary CareCare) Who Graduated from WV's ) Who Graduated from WV's Three Medical Three Medical
SchoolsSchools 7 to 10 Years Earlier7 to 10 Years Earlier
400
450
150
200
250
300
350
umbe
r of
Gra
duat
es
Outside WVWithin WVUrban WVRural WV
0
50
100
1981 1986 1991 1996 2001 2006
Year
Nu
Pathman Report FindingsPathman Report Findings
"As of 2006, 13% of physicians who "As of 2006, 13% of physicians who graduated from all 3 med schools 7graduated from all 3 med schools 7--graduated from all 3 med schools 7graduated from all 3 med schools 710 years earlier were working within 10 years earlier were working within rural areas of the state 7 to 10 years rural areas of the state 7 to 10 years after graduation.“after graduation.“
"Among primary care graduates, the "Among primary care graduates, the ti ki i l f ti ki i l f proportion working in rural areas of proportion working in rural areas of
West Virginia remained stable from West Virginia remained stable from 1991 to 2006, at about 14%."1991 to 2006, at about 14%."
17
Location of Location of Primary CarePrimary Care Physicians Who Graduated from Physicians Who Graduated from WV's WV's Three Medical SchoolsThree Medical Schools 7 to 10 Years Earlier7 to 10 Years Earlier
200
250
100
150
200N
umbe
r of
Gra
duat
es
Outside WVWithin WVUrban WVRural WV
0
50
1981 1986 1991 1996 2001 2006
Year
N
Pathman Report FindingsPathman Report Findings
Among graduates of all 3 medical Among graduates of all 3 medical schools "As of 2006 more than schools "As of 2006 more than schools, As of 2006, more than schools, As of 2006, more than half (54%) were practicing in half (54%) were practicing in primary care specialties 7 to 10 primary care specialties 7 to 10 years after graduation. years after graduation.
Thi i i ifi tl hi h Thi i i ifi tl hi h This is a significantly higher This is a significantly higher proportion than reported proportion than reported elsewhere for graduates of other elsewhere for graduates of other statesstates."."
18
Pathman Report FindingsPathman Report FindingsOverall, the proportion of graduates of WV's Overall, the proportion of graduates of WV's three schools practicing in rural areas of WV three schools practicing in rural areas of WV was decreasing from 1986 to 1996, then was decreasing from 1986 to 1996, then turned around and increased from 1996 to turned around and increased from 1996 to 2006200620062006
1996 to 2006 is the exact time period when 1996 to 2006 is the exact time period when WVRHEP participants were graduating and WVRHEP participants were graduating and appearing in the workforce. appearing in the workforce.
“We cannot know for sure, but can suspect “We cannot know for sure, but can suspect th t th d t d f 1996 t 2006 i th t th d t d f 1996 t 2006 i that the upward trend from 1996 to 2006 is that the upward trend from 1996 to 2006 is due to RHEP and that the impact of RHEP due to RHEP and that the impact of RHEP was to convert a falling rate of rural was to convert a falling rate of rural physician production from the state's physician production from the state's schools to a 86% increase, with the schools to a 86% increase, with the percentage of WV grads practicing in rural percentage of WV grads practicing in rural WV from 7% WV from 7% (1996) to 13% (2006).”(1996) to 13% (2006).”
Pathman Report Findings, con’tPathman Report Findings, con’tSignificant finding is that in 20 to 25 years, Significant finding is that in 20 to 25 years, WV has reversed the medical school origins of WV has reversed the medical school origins of physicians practicing in WV. physicians practicing in WV.
These graphs show that in 1981 far more of These graphs show that in 1981 far more of WV's physicians were trained in other states WV's physicians were trained in other states and internationally than were trained in state and internationally than were trained in state schoolsschools
With th i d ti f With th i d ti f With the expansion and creation of new With the expansion and creation of new schools in the 1970s and 1980s that by 2006 schools in the 1970s and 1980s that by 2006 significantly more physicians practicing in WV significantly more physicians practicing in WV were trained in WV than were trained were trained in WV than were trained elsewhere.elsewhere.
19
Changes from 1981 to 2006 in Number of Clinically Active Physicians Changes from 1981 to 2006 in Number of Clinically Active Physicians in WV Who Graduated from Medical Schools within the State, in WV Who Graduated from Medical Schools within the State,
Elsewhere in the US and Canada, and Outside the USElsewhere in the US and Canada, and Outside the US
1600
1800
600
800
1000
1200
1400
umbe
r of P
hysi
cian
s
InternationalU.S./CanadaWest Virginia
0
200
400
1981 1986 1991 1996 2001 2006
Year
Nu
Changes from 1981 to 2006 inChanges from 1981 to 2006 in Number of Clinically Active Physicians Number of Clinically Active Physicians in RURAL WV Who Graduated from Medical Schools within the State, in RURAL WV Who Graduated from Medical Schools within the State,
Elsewhere in the US and Canada, and Outside the USElsewhere in the US and Canada, and Outside the US
500
600
200
300
400
500
mbe
r of P
hysi
cian
s
InternationalU.S./CanadaWest Virginia
0
100
1981 1986 1991 1996 2001 2006
Year
Num
20
Oct 2006 HRSA Health Oct 2006 HRSA Health Workforce study (2004 data)Workforce study (2004 data)
31% of WV’s physician 31% of WV’s physician p yp yworkforce are graduates of workforce are graduates of instate medical schools while instate medical schools while national average is 29%. national average is 29%.
38% of the WV physician 38% of the WV physician workforce are international workforce are international graduates, compared to a graduates, compared to a national average of 26%.national average of 26%.
Comparison of AMA Master file Data and WVRHEP Data on Percentage of WV Medical Graduates working in WV and in Rural WV
AMA Master file Data WVRHEP data
Percentage of WV medical school graduates
40% of those students who graduated between
37% for those students who graduated betweenmedical school graduates
working in WVwho graduated between
1996-1999who graduated between
1998-2005
Percentage of WV medical school graduates working in rural* WV
13% of those students who graduated between
1996-1999
11.3% for those students who graduated between
1998-2005
Percentage of West Virginia School of
22% of the WVSOM students who graduated
19% of the WVSOM students who graduatedVirginia School of
Osteopathic Medicine (WVSOM) graduates working in rural* WV
students who graduated between 1996-1999
students who graduated between 1998-2005
*Urban = the 12 metropolitan counties identified by the OMB in 1999 + Monongalia County (the home of WVU Health Sciences Center). Rural = the 42 other WV counties.
21
NRHA Policy Papers on RH NRHA Policy Papers on RH WorkforceWorkforce
Defining the Issues and Principles Defining the Issues and Principles of R&Rof R&R
http://www.ruralhealthweb.org/go/left/polichttp://www.ruralhealthweb.org/go/left/policyy--andand--advocacy/policyadvocacy/policy--documentsdocuments--andand--statements/issuestatements/issue--paperspapers--andand--policypolicy--briefs/briefs/
Visit us Visit us on the on the WebWeb
www.wvrhepahec.org
www.wv-hsta.org
22
Contact InformationContact Information
www.wvrhepahec.orgwww.wvrhepahec.org
Hilda R. HeadyHilda R. Heady304.293.4966304.293.4966304.288.9003304.288.9003hheady@[email protected]