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Data Chartpack

Data Chartpack. Recruitment and retention of Colorado ’ s primary care workforce: Rural/urban differences . October 22, 2009. 2 nd Colorado Health Professions Workforce Summit. Overview of CHI study. Five areas of inquiry -- Workforce diversity Educational pipelines Aging of the workforce

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Data Chartpack

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  1. Data Chartpack Recruitment and retention of Colorado’s primary care workforce: Rural/urban differences October 22, 2009 2nd Colorado Health Professions Workforce Summit

  2. Overview of CHI study Five areas of inquiry -- • Workforce diversity • Educational pipelines • Aging of the workforce • Career ladders • Scopes of practice and collaborative models of care Three primary care health professionals reviewed -- • Physicians • Nurses • Oral health providers (dentists and dental hygienists)

  3. Study methods • Synthesis of peer-reviewed literature and available Colorado data • Literature review included abstract reviews and analyses of evidence-based studies • Analysis of CHI health professions’ workforce surveys by age, geography, race/ethnicity and other relevant variables (2005-09 surveys)

  4. PHYSICIANS

  5. Physician diversity: What the literature says… Effects on access to care • Minority physicians are providing a disproportionate share of care to the underserved1 • Minority status is a stronger predictor of service to the underserved than National Health Service Corp participation, socioeconomic background or growing up in underserved area2 • Lack of cultural sensitivity by health professionals is associated with reduced care-seeking by parents for their children3 • Diversity among medical school students is associated with higher levels of cultural sensitivity of all students and greater willingness to serve diverse populations4

  6. Physician diversity: What the literature says… Effect on health outcomes • Language barriers between physicians and patients increase costs and potential for medical errors5 • Cultural competency/racial concordance are associated with higher patient satisfaction and levels of patient participation in their care6 • Lack of cultural understanding and awareness can lead to withholding information, noncompliance, delays in care and incorrect diagnoses7

  7. Physician diversity: What the literature says… Effects on patient satisfaction Racial/ethnic identification with physician is associated with: • Improved satisfaction among minority patients8 • Higher perceived quality of care9, 10 • Higher levels of patient participation in their care11

  8. Physician diversity: A Colorado perspective Race/ethnic background of licensed, active Colorado physicians SOURCE: United States Census: 2008 Population Estimates, Colorado Health Institute 2005 Physician Workforce Survey (Q2), 2009 Rural Physician Survey (Q10)

  9. Physician diversity: A Colorado perspective Payer mix by physician race/ethnicity, rural practice, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q10, Q27)

  10. Physician diversity: A Colorado perspective Percent Responding “Interested” (4 or 5) SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q10, Q29)

  11. Physician pipeline: What the literature says… KEY FINDINGS • The success of particular pipeline interventions such as pairing middle and high school students with mentors to increase students’ interest in the health professions varies depending on age of student12 • Pipeline programs and interventions can have an effect on physician supply13 • Selective admissions, institutional commitment, debt forgiveness and other efforts are effective in promoting rural practice and primary care specialties14

  12. Physician pipeline: What the literature says… Factors associated with choosing a rural practice • Growing up rural15 • Selective admissions by medical school16 • Medical school focus on primary care and rural medicine17 • Financial incentives, such as NHSC funding18 • Medical school experiences, such as rural clinical rotations19

  13. Physician pipeline: What the literature says… FACTORS ASSOCIATED WITH CHOICE OF PRIMARY CARE PRACTICE • Interest at time of admission to medical school20 • Selective admissions policies of medical school21 • Growing up rural22 • Having less medical school debt23 • School’s commitment to primary care practice24 • Being female25

  14. Physician pipeline: A Colorado perspective Where physicians practicing in rural Colorado grew up and state conferring medical degree, 2009 SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q32, Q9)

  15. Physician pipeline: A Colorado perspective • Two medical schools in Colorado (DO and MD) • 132 MD graduates in 2008—UC Denver only; no graduates from Rocky Vista (DO) until 2012 • Colorado family medicine residency graduates: • Of 172 family medicine residents in 2007-09, 114 remained in Colorado to practice • Approximately 87% of Colorado’s family medicine residents are from out of state SOURCE : American Association of Medical Colleges Graduation Data, 2009, Correspondence – TonyPrado-Gutierrez, University of Colorado at Denver

  16. Aging of the physician workforce: What the literature says… Key finding Many retired physicians are interested in volunteering after retirement, but barriers include malpractice concerns, paperwork and bureaucracy26

  17. Aging of the physician workforce: A Colorado perspective Proportion of physician workforce and overall Colorado workforce, age 55 and older, 2009 Proportion of rural Colorado primary care physicians by age group, 2009 * Primary care includes family medicine, general pediatrics and internal medicine SOURCE : U.S. Census Bureau 2008 Workforce Estimates, Colorado Health Institute 2009 Rural Physician Survey (Q8, Q4), Peregrine Database April 2009

  18. Aging of the physician workforce: A Colorado perspective Volunteerism and part-time practice among Colorado’s rural practicing physicians by age, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q2, Q8)

  19. Collaborative care models: A Colorado perspective Percent of rural physicians reporting mid-level providers (MLPs) in their practice, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q17)

  20. Registered Nurses (RNs) and Licensed practical nurses (LPNs)

  21. Diversity in the nursing workforce: What the literature says… • Literature does not include evidence-based studies on nursing diversity/cultural competence relative to patient outcomes and satisfaction • Further research warranted to assess these relationships in the practice of nursing

  22. Diversity in the nursing workforce: A Colorado perspective Fluency in language other than English used to communicate with patients, RNs (2008) and LPNs (2007) SOURCE: Colorado Health Institute 2008 Registered Nurse Survey (Q38), 2007 Licensed Practical Nurse Survey (Q34, Q34b)

  23. Nursing pipeline: What the literature says… • Non-competitive faculty salaries contribute to faculty shortages27 • A variety of approaches around the country have successfully improved nursing student enrollment: • Changing to year-round academic schedule and year-long faculty appointments at University of Nevada Las Vegas28 • In Colorado, partnership between Poudre Valley Hospital and University of Northern Colorado29

  24. Nurse pipeline: A Colorado perspective • 24 accredited 2-year associate degree in nursing (ADN) degree programs • 11 accredited 4-year bachelor of science in nursing (BSN) degree programs • 10 accredited licensed practical nurse (LPN) programs • 15 accredited 2-year and one 4-year nursing programs with LPN exit option SOURCE: Colorado State Board of Nursing

  25. Nurse pipeline: A Colorado perspective Colorado nursing program graduates, 2007 Area where nurse grew up and was educated, active RNs (2008) and LPNs (2007) SOURCE: Colorado State Board of Nursing, Colorado Health Institute 2008 RN Survey (Q4, Q34), 2007 LPN Survey (Q1a, Q30)

  26. Nursing pipeline: A Colorado perspective PIPELINE CAPACITY ISSUES • Wait lists—3,579 qualified applicants not admitted due to lack of slots (2008-09) • Faculty vacancies (2008) • 15% of associate degree in nursing (ADN) faculty positions • 8% of bachelor of science in nursing (BSN) faculty positions • 15% of licensed practical nurse (LPN) faculty positions • 11% of master of science in nursing (MSN) faculty positions • 17% of doctor of nursing practice (DNP) faculty positions • 76 FTE vacancies for clinical nurse instructors • Reported barriers to program expansion include faculty shortages, securing clinical placements, lack of funds, noncompetitive salaries for faculty SOURCE: Colorado Health Institute 2008/2009 Nursing Faculty Studies

  27. Aging of the nurse workforce: What the literature says… • Incentives such as improved benefits, flexible schedules, ergonomic improvements in the work environment and institutional support/recognition can influence older nurses to delay retirement30 • Turnover highly expensive both monetarily and in terms of loss of expertise31 • No single retention strategy works across all settings, multiple factors involved32

  28. Aging of the nursing workforce: A Colorado perspective Proportion of RN (2008) and LPN (2007) workforce age 55 and older SOURCE: Colorado Health Institute 2008 RN Survey (Q36, Q17), 2007 LPN Survey (Q19, Q31)

  29. Aging of the nursing workforce: A Colorado perspective OF NURSES PLANNING TO LEAVE THE WORKFORCE: • 14% of non-rural and 10% of rural RNs ages 55 and older reported planning to leave their primary nursing position in next 12 months (2008) – Highest reported reasons included insufficient wages, too much stress, insufficient benefits, lack of respect and retirement • 15% of non-rural and 25% of rural LPNs ages 55 and older planned to leave their primary nursing position in next 12 months (2007) – Highest reported reasons included too much stress, insufficient wages, retirement, workplace safety issues, and not feeling respected SOURCE: Colorado Health Institute 2008 RN Survey (Q29, Q30, Q36), 2007 LPN Survey (Q25, Q36, Q31)

  30. Nurse scope of practice/models of care: What the literature says… • Nurse practitioners (NPs) deliver comparable quality of care to physicians within the scope of their practice • Patients report greater satisfaction with NPs and certified nurse midwives (CNMs) than with physicians in specific care settings • NPs and CNMs are more likely to work in an underserved area and/or with an underserved population SOURCE: Colorado Health Institute, Collaborative Scopes of Care Study, 2009

  31. Nurse scope of practice/collaborative models of care: A Colorado perspective • More than 80% of RNs agreed that their relationship with physicians was good (2008) • Most nurses (74% non-rural and 77% rural) agreed that they participated in decisions related to their patients’ care • Approximately 2,322 practicing nurse practitioners in Colorado* * The American Academy of Nurse Practitioners estimates that 90% of registered NPs are practicing in the field; Colorado had 2,580 actively licensed nurse practitioners as of January 5, 2009. SOURCE: Colorado Health Institute 2008 RN Survey (Q23), Colorado Department of Regulatory Agencies

  32. Career ladders in nursing: What the literature says… • Robust career ladder opportunities are associated with increased productivity and satisfaction among nurses33 • Two general types of career ladders34 • Clinical ladder achieved through on-the-job performance and clinical evaluation • Educational ladder based on obtaining higher degrees

  33. Career ladders in nursing: A Colorado perspective Highest degree earned by practice location, active RNs, 2008 SOURCE: Colorado Health Institute 2008 RN Survey (Q1, Q2, Q7)

  34. Career ladders in nursing: A Colorado perspective • Pursuit of additional education: • More non-rural than rural nurses reported having returned to school for an additional degree • Greater proportion of nurses with bachelor’s degrees in nursing (BSNs) returned to school for additional nursing degrees • RNs whose first degree was an associate degree in nursing (ADN) began and ended their education later than BSN graduates SOURCE: Colorado Health Institute 2008 RN Survey (Q2, Q7)

  35. Career ladders in nursing: A Colorado perspective • Type of facility where first employed • More older, non-rural LPNs began work in hospitals • More younger, non-rural LPNs began work in nursing homes, clinics or physician offices • Pursuit of additional education • 15% of non-rural and 18% of rural LPNs reported currently being enrolled in an RN program • 36% of non-rural and 43% of rural LPNs reported plans to pursue an RN education SOURCE: Colorado Health Institute 2007 LPN Survey (Q7, Q7a, Q10, Q11, Q31)

  36. Dentists and Dental Hygienists

  37. Diversity among oral health professionals: What the literature says… • Racial/ethnic minority dentists more likely to care for underserved patients35 • Lack of cultural understanding by dentists associated with barriers to care-seeking for Medicaid-enrolled children36 • Available literature did not address diversity in the dental hygiene workforce

  38. Oral health professionals and diversity: A Colorado perspective SOURCE: U.S. Census Bureau 2008 population estimates, Colorado Health Institute 2008 Rural Dentist Survey, 2006 Dental Hygienist Survey

  39. Diversity among oral health professionals: A Colorado perspective Language proficiency among dental hygienists (2006) and rural dentists (2008) SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

  40. Diversity among oral health professionals: A Colorado perspective • 27.5% of rural dentists indicate they speak a language other than English to communicate with some or all patients • 6.4% of urban/suburban and 5.9% of rural dental hygienists report being fluent in a language other than English SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

  41. Diversity among rural oral health professionals: A Colorado perspective • Minority rural dentists report spending greater proportion of time in direct patient care with children and older adults • Payment sources • More minority rural dentists offer a sliding-fee schedule than White rural dentists • More minority rural dentists report accepting Medicaid payment, new Medicaid patients, Child Health Plan Plus (CHP+) payment and new CHP+ patients • Non-White dental hygienists report twice as many volunteer hours as White dental hygienists • More non-White dental hygienists report that their primary worksite provides care to Medicaid patients, accepts new Medicaid patients and provides care on a sliding-fee schedule SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q3, Q20, Q22), 2006 Dental Hygienist Survey (QB3b, QC5, QB16, QB16a)

  42. Dentist pipeline: What the literature says… • Perceived barriers to dental students’ practicing in underserved areas/populations include lack of information about practice opportunities, student debt and lack of access to patient populations in dental school37 • Untested effectiveness of dental pipeline interventions to promote service to underserved populations38 • Secondary school interventions and select characteristics of dental school admissions and curriculum known to promote dental graduates practice with underserved populations39

  43. Dentist pipeline: A Colorado perspective SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q24, Q32)

  44. Dentist pipeline: A Colorado perspective Factors important in the decision to practice in a rural community, 2008 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q12)

  45. Dental hygienist pipeline: A Colorado perspective Dental hygienist background by work location, 2006 Type of dental hygiene degree of dental hygienists by work location, 2006 SOURCE: Colorado Health Institute 2007 Dental Hygienist Survey (QA1, QC1, QC2, QB5, QA2)

  46. Aging of the oral health workforce: A Colorado perspective • 41% of rural dentists are age 55 and older • Greater proportion of older rural dentists support the independent dental hygienist practice • 13% of rural dental hygienists are age 55 and older SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q1, Q34), 2007 Dental Hygienist Survey (QC7, QC1)

  47. Oral health scopes of practice: What the literature says… • Peer-reviewed studies indicate that dental hygienists provide equal or better quality of care within scope of practice • Vast majority of dental hygienist patients are satisfied with care SOURCE: Colorado Health Institute, Collaborative Scopes of Care Report, 2009

  48. Oral health scopes of practice/collaborative models of care: A Colorado perspective • 51% of rural dentists indicate they collaborate with physicians/nurses in the community • 72.8% work with at least one dental hygienist • 25% indicate support for expanding the role of dental hygienists as independent practitioners • 3% of dental hygienists statewide report working in independent practice SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q17, Q33, Q34), 2007 Dental Hygienist Survey (QB6)

  49. Dental hygienist career ladders: What the literature says… A 2008 study found that a greater proportion of dental hygienists who begin their dental hygiene career with a bachelor’s degree • Have or are seeking a master’s degree • Are in faculty positions or other teaching positions • Are involved in research40

  50. Dental hygienist career ladders: A Colorado perspective Highest degree (dental hygiene or other) obtained by working dental hygienists, 2006 Dental hygienists intending to pursue another degree/certification, 2006 SOURCE: Colorado Health Institute 2008 Dental Hygienist Survey (QB5, QA2, QA4)

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