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Service-Requiring Scholarships and Loan Repayment for Nurses in the Southeast
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Do NHSC Dentist Alumni Remain in the Oral Health Safety Net?
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Developing Productivity Measures for Workforce Programs
Allied Health Workforce Needs Assessments: Lessons Learned
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Differential Nursing Employment Patterns: A Region 4 Analysis of Race and Ethnicity
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Primary Care Physician Availability and Access to Quality Care
References

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Service-Requiring Scholarships and Loan Repayment for Nurses in the Southeast

Background and Objectives: Both the U.S. government and states use service-requiring scholarships and loan repayment incentives to entice nurses into shortage areas. The recent NHSC reauthorization (US Congress, 2002 P.L. 107-251, Health Care Safety Net Amendments of 2002) stipulates that not less than 10% of all Corps scholarship and loan repayment funds are to support nurse practitioners, nurse midwives and physician assistants. Given the lower educational costs for nurses relative to physicians, this requirement means that approximately one-quarter of NHSC awards will go to nurses. While the NHSC does not support training for RNs and LPNs, HRSA’s Nursing Education Loan Repayment Program (NELRP) and Nursing Scholarship Program (NSP) do, the former making 574 new awards in 2003 (http://bhpr.hrsa.gov/nursing/loanrepay.htm) and the latter awarding approximately 120 new scholarships in 2004 (http://bhpr.hrsa.gov/nursing/scholarship).

Through the early and mid 1990s, states created many new support-for-service programs for advanced-practice nurses and as of 1996, 36 state-run programs supported 1,036 nurse practitioners, nurse midwives and physician assistants (Pathman et al., 2000). Given the rapid rise in these state programs through the mid-1990s, it is likely that their current number and the size of their combined workforce have grown further. States similarly provide support-for-service programs for RNs and LPNs, but these programs have not been cataloged and the size of their workforce is unknown. Given the size and importance of nursing shortages in the Southeast as elsewhere, and given the recent growth—without demonstrated effectiveness—of programs that attempt to meet the needs of areas with greatest shortages through training support in exchange for service obligations, we propose to provide both descriptive and evaluative data on these important programs in this region.

Project goals will be to (1) identify all programs in each state of the region that provide financial support for training costs to entice RNs, LPNs, NPs and CNMs to needy areas, and describe the basic operations of each program (e.g., contract terms, workforce sizes, eligibility criteria for service sites, nurse recruitment methods, proportion of positions filled, challenges faced); (2) identify and similarly characterize programs in each of these states that are funded jointly by the NHSC and states; (3) combine this information into an overall characterization of the region’s nurse-supporting programs and their combined workforce size and composition, new program directions and challenges; and (4) clarify how federal and state programs augment and/or duplicate one another in this region and identify the lessons that each can learn from the other (e.g., successful recruitment methods, effective nurse-site matching processes). This study will identify state programs using available compendia, internet searches, and phone contacts with the region's state offices of rural health and financial aid offices in schools of nursing. Information about identified state and federal programs will be gathered through a telephone and written survey of program directors and from all available printed and on-line information (e.g., program annual reports, in-state audits, annual appropriation documents). The findings of this study will be submitted for publication and information detailing specific programs assembled into a technical report. This collaborative project will draw on the shared and complementary skills of its co-principal investigators, Barbara Mark (nursing) and Don Pathman (medicine), and Cheryl Jones (nursing).

Potential policy relevance: Policy decisions with regard to the effectiveness of different types of federal, state, and local programs -- in terms of both ensuring an adequate supply of nurses in shortage areas and increasing retention rates in these areas -- depends on obtaining comprehensive and adequate data about these programs. Data obtained in this project will allow us to make recommendations regarding support for programs which best meet these goals. (back to top)

Do NHSC Dentist Alumni Remain in the Oral Health Safety Net?

Background and objectives: Oral health care access remains a problem in North Carolina and the Southeast. Only 1 in 5 North Carolina dentists has 10 or more Medicaid patients per quarter, but higher Medicaid participation rates were found among minority dentists, pediatric dentists, and those in rural areas (Mayer, 2000) and among NHSC dentist alumni nationally (Mofidi et al., 2002). Since 1980, the NHSC has placed over 350 dentists in underserved areas across the US, but fewer than 100 have been deployed to DHHS Region IV where 55 million people have about 30,000 dentists - 1 dentist per 1850 population, less than a 1:1,500 ratio nationally. Because few state-funded health professional service obligation loan programs target dentists (Pathman, et al 2000a, 2000b), the NHSC is likely to remain a major source of oral healthcare safety net workforce in the region and nationally.

This two-year project investigates whether NHSC alumni are more likely than other similar dentists to continue to work in safety net settings and to serve more Medicaid beneficiaries after completion of their service obligations. Positive findings would support expansion of dental positions in the NHSC and/or greater emphasis on dentists in state scholarship and loan repayment programs in the Southeast. Data used include: (1) NHSC dentists lists and survey data from UNC’s HRSA sponsored NHSC evaluation (1997-2000); (2) archived North Carolina dental license files; (3) a list of North Carolina safety-net dental practice sites. A survey of North Carolina NHSC alumni and comparison cohort of non-NHSC alumni dentists will be conducted by the UNC to inquire about safety net practice, Medicaid intensity, beliefs about community access for underserved populations, and retention expectations. Access to dental care provided by NHSC alumni and other dentists will be compared after controlling for important sociodemographic and practice covariates through multivariate analyses.

Potential policy relevance: Given this context, North Carolina’s Secretary of Health and Human Services has stated that improving access to dental care in North Carolina is one of her top health policy priorities (Odom, 2002). Other states in the region also have focused increasing attention on access to dental care since the publication of the Surgeon General’s Report on Oral Health (US DHHS, 2000). Participation by private dental practitioners in the Medicaid program is suboptimal, and current budget conditions will limit the ability of most states to substantially increase dental reimbursement rates to encourage greater participation. Thus, safety-net dental providers will continue to provide critical access to dental care for low-income populations. In North Carolina the number of safety-net dental clinics has nearly tripled over the past several years (NC Oral Health Section, 2002). State and local public health agencies and community health centers have devoted considerable resources to recruiting and retaining dental providers to staff these new clinics. Revitalization and expansion of the NHSC dental program are likely to aid these state and local efforts in a meaningful way by providing recruitment incentives in the form of loan repayment and enhancing educational opportunities through the NHSC scholarship program. These programs also will help to diversify the dental workforce. Yet, like other dentists, NHSC alumni have identified poor Medicaid reimbursement rates and administrative hassles as discouraging their continued practice in safety net settings and treatment of Medicaid beneficiaries after completion of their federal service obligation (Konrad et al., 2000; Mofidi et al., 2002). Despite these impediments, we expect that, compared with other dentists, NHSC alumni will have more initial experience and continuing interest in working with traditionally underserved populations. As a result, we hypothesize that NHSC alumni will be more likely to work in safety net settings and will serve more Medicaid beneficiaries after completion of their service obligations. Such a finding would support expansion of the dental component of the NHSC and/or greater emphasis on dental practitioners in state scholarship and loan repayment programs in the Southeast.(back to top)

Developing Productivity Measures for Workforce Programs

Background and objectives: Almost all government programs, state and especially federal, are subject to new accountability standards. This is a result, in part of the Government Performance and Results Act (GPRA) and similar state enacted legislation or executive action. The development of credible, reliable and informative measures for many workforce development programs supported by government is difficult to achieve. The accountability and evaluability of programs is difficult in this field; this was made apparent as part of our work on the National Evaluative Study of AHECs, where state programs were struggling with specific measures and the program, overall, was attempting to implement useful measures. Current measures applicable to BHPr programs depend largely on process measures. We will develop a formal proposal to create alternative productivity and evaluation measures for programs that address outcomes and impacts of training, placement, and support programs. This will build on our work with the SRAP evaluation which links process and outcome measures through a logic model but also include appropriate denominators for the impacts. A typical characteristic of workforce enhancement programs is the involvement of many multiple agencies, programs and organizations that affect workforce supply and distribution and creating a metric that measures incremental contributions or failures of various components will be very difficult to achieve. (back to top)

Allied Health Workforce Needs Assessments: Lesson Learned

Background and objectives: While shortages of nurses, pharmacists and other licensed health professionals have gathered recent attention, shortages of unlicensed allied health professionals have also emerged across the United States. Surveys conducted by the American Hospital Association (AHA) reveal a strong unmet demand for radiologic technologists, clinical lab technicians, and cytotechnologists. The need for allied health practitioners is further intensified by the need for qualified faculty to teach in allied health profession institutions. The Association of Schools of Allied Health Professions' Faculty Survey reveals most allied health programs struggle to fill open faculty positions, and it projects increased difficulty in the future. While the need for specific allied health professionals is clearly articulated, states continue to struggle with the key workforce questions of affordability and applicability. The estimation of the needs and demands for allied health professions is a difficult and uncertain process for the following reasons: most of the allied health workforce is not licensed, and although encouraged by some employers, certification is optional; a significant proportion of allied health professionals choose not be credentialed and are not accounted for in any data sets collected from credentialing organizations and cannot be fully enumerated; and, for those who are credentialed, there is often more than one certifying organization. The objective of this project is to provide states and the BHPr with important lessons learned from a successful, collaborative, allied health workforce assessment model. To date, the Cecil G. Sheps Center for Health Services Research has produced six allied health reports. The professions studied were: Physical Therapy (2000), Speech-Language Pathology (2001), Health Information Management (2002), Radiologic Sciences (2003), Respiratory Care (2004) and Clinical Lab Sciences (2004). These reports have provided important information on each of the professions studied, but this project will provide a synthesis of the common themes identified in the studies.

Potential policy relevance: Although the professions studied have varied, including both rehabilitation and diagnostic professions, similar themes and lessons learned have been identified. These themes are generalizable across the allied professions and are critical to improving workforce supply, distribution and diversity. This analysis will provide states and the BHPr with important lessons learned from a successful assessment model developed for studying the allied health workforce in North Carolina that can be included in policy application in other states. (back to top)

Differential Nursing Employment Patterns: A Region 4 Analysis of Race and Ethnicity

Background and objectives: Recent reports have highlighted the discrepancy between the racial and ethnic composition of the registered nurse (RN) workforce and the composition of the population at large (Buerhaus & Auerbach, 1999; Dower et al., 2001). In 2000, African Americans represented approximately 21.6% of the population, but only 8.4% of the State’s RN workforce; Latinos represented about 4.7% of the population, but less than 0.5% of the RN workforce (N.C. Center for Nursing). There is some evidence that individuals are more comfortable interacting with, and empowered by health professionals of the same racial or ethnic background and that professionals who share a common background with the person(s) to whom they provide care may be more aware of and sensitive to their beliefs, values, and cultures (Coffman, Rosenoof & Grumbach, 2001). The under-representation of persons from racial and ethnic backgrounds in the nursing and health care workforce raises questions about the ability of the health care system to provide access to care and eliminate racial and ethnic disparities in health.

This issue is compounded by larger problems in the nursing workforce. There is an increasingly constrained labor market for RNs, as reports of shortage, understaffing, unsafe working conditions, overall dissatisfaction in the nursing profession, patient safety concerns, and the aging RN workforce appear in the press (Aiken et al., 2002; Berens, 2000; Buerhaus, Staiger, & Auerbach, 2000; Carpenter, 2000; Needleman et al., 2002). The current shortage of nurses raises concerns about employment shifts in the workforce, as RNs leave their jobs in search of better working conditions and/or higher pay, move from full-time to part-time employment, or leave the profession entirely (Ehrenberg & Smith, 1991). Broad strategies typically suggested for resolving labor market instability and cyclic shortages (i.e., improving wages, working conditions, and the image of nursing) do not necessarily address how and why nurses from specific racial and/or ethnic groups move within or leave the nursing profession. Very little is known about patterns of employment among nurses; even less is known about how these patterns vary overall, and by race or ethnicity. Thus, it is not currently possible to design and target recruitment and retention strategies that are likely to be successful.

The objective of this project is to provide information on nursing employment patterns for different racial and ethnic groups within Region IV, to serve as a basis for developing effective recruitment and retention strategies and ensure a highly qualified and diverse nursing workforce to meet changing societal needs. Differential patterns of employment for nurses in the region overall, and by race and ethnicity will be examined. Mobility in the regional workforce will be explored by testing hypotheses of differential nursing employment patterns relative to demographic (including race/ethnicity), professional, employment and economic factors. This approach will provide a better understanding of nursing mobility within Region IV, with an eye toward recruiting and retaining a highly qualified and diverse nursing workforce.

Potential policy relevance: It is critically important to prepare a diverse nursing workforce to meet societal demands, however ensuring such a diverse workforce is a difficult task. It is unclear how nurses, in general, and those of different racial and ethnic characteristics respond to problems in the workforce. For example, do nurses of different racial or ethnic groups change jobs at a different rate than others? If so, do they move to different jobs with the same employer, take a similar job with a different employer, or change jobs and employers altogether? Do they move to different geographic locations? What are the reasons for their job change? Do they leave nursing entirely? And if so, why? Knowledge of nurses’ job change and behaviors can aid in understanding whether and how certain characteristics influence job change decisions, and can serve as a basis upon which regional policy-makers can develop strategies to recruit and retain a diverse nursing workforce. Such an approach will go beyond addressing the cyclic shortage of nurses, and will focus on improving patients’ access to care. Moreover, developing nurse recruitment and retention strategies based on the best available data is likely to be more meaningful and successful in attaining diversity within nursing than the ad hoc approaches in use today. (back to top)

Primary Care Physician Availability and Access to Quality Care

References

Aiken LH, Clarke SP, Sloane DM, Sochalski J, & Silber JH. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 288(16):1987-1993.

Andersen R. (1995). Revisiting the Behavioral Model and Access to Medical Care. J Health and Social Behavior. 36:1-10.

Andersen RM, McCutcheon A, Aday LA, Chiu GY, Bell R. (1983). Exploring Dimensions of Access to Medical Care. Health Services Research. 18(1):49-74.

Berens MJ. (2000, September 10). Nursing mistakes kill, injure thousands: Cost-cutting exacts toll on patients, hospital staffs. The Chicago Tribune [On-line].  Available: http://www.chicagotribune.com/ news/nationworld/article/0,2669,2-46844,FF.html.

Buerhaus PI, & Auerbach D. (1999). Slow growth in the United States of the number of minorities in the RN workforce. Image - the Journal of Nursing Scholarship. 31(2):179-183.

Buerhaus PI, Staiger DO, & Auerbach DI. (2000). Implications of an aging registered nurse workforce. JAMA. 283(22):2948-2954.

Carpenter D. (2000). Going, going, gone: Nurses and other staff bid hospitals farewell. Hospitals and Health Networks. 74(6):32-42.

Coffman JM, Rosenoff E, & Grumbach K. (2001). Racial/Ethnic disparities in nursing. Health Affairs. 20(3): 263-272.

Dower C, McRee T, Briggance B, & O'Neil EH. (2001). Diversifying the nursing workforce: A California imperative. San Francisco, CA: California Workforce Initiative at the UCSF Center for the Health Professions.

Ehrenberg RG, & Smith RS. (1991). Modern labor economics: Theory and public policy (4th ed.). New York: Harper Collins Publishers.

Knickman J. (1998). A Foundation Executive on Access Measures. Health Affairs. 17(1):187-8.

Konrad TR, Leysieffer K, Stevens C, et al. (2000). Evaluation of the Effectiveness of the National Health Service Corps: Final Report HRSA. 240-95-0038. Chapel Hill, NC: Sheps Center and MPR. http://www.shepscenter.unc.edu/research_programs/primary_care/execsum.pdf.

Mainous AG, 3rd, Hueston WJ, Love MM, & Griffith CH, 3rd. (1999). Access to care for the uninsured: is access to a physician enough? American Journal of Public Health. 89(6):910-2.

Mayer ML, Stearns SC, Norton EC, Rozier RG. The effects of Medicaid expansions and reimbursement increases on dentists' participation. Inquiry. 37:33-44

Mofidi MM, Konrad TR, Porterfield D, Niska R, Wells B. (2002). Provision of Care to the Underserved by National Health Service Corps Alumni Dentists. Journal of Public Health Dentistry. 62(2):102-108.

Mofidi M, Rozier RG, King RS. (2002). Problems With Access to Dental Care for Medicaid-Insured Children: What Caregivers Think. American Journal of Public Health. 92(1):53-58.

Needleman J, Buerhaus P, Mattke S, Stewart M, & Elevinsky K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal Of Medicine. 246(22):1715-1722.

North Carolina Center for Nursing. (2002). North Carolina Trends in Nursing: 1982-2000. RN and LPN Workforce Demographics. Retrieved December 19, 2002 at http://www.ga.unc.edu/NCCN/research/Trends2000/workforce_demos.pdf.

Odom CH. (2002). Presentation at the 2002 NC State Health Director's Conference, Raleigh, NC. February 1, 2002.

Pathman DE, Konrad TR, Taylor DH, et al. (2000a). Study of state service contingent programs for health providers and minority supplement. Final Report AHRQ R01 HS 09165, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

Pathman DE, Taylor DH, Konrad TR, et al. (2000b). The many state scholarship, loan forgiveness and related programs: the unheralded safety net. JAMA. 284(16):2084-2092.