4
Human Resources

SUMMARY

An adequate supply of properly educated health care professionals is critical to meeting the health needs of rural and frontier communities. Experientially based education programs should be enhanced to ensure that all health professionals master the core competencies necessary to provide high-quality care (i.e., provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics).

Efforts should also be made to boost the supply of health professionals in rural areas. A multifaceted approach to the recruitment and retention of health professionals is needed, including interventions at every point along the rural workforce pipeline: (1) enhanced preparation of rural elementary and high school students to pursue health careers; (2) stronger commitment of health professions education programs to recruiting students from rural areas, educating and training students in rural areas, and adopting rural-appropriate curricula; and (3) stronger incentives for health professionals to seek and retain employment in rural areas.

Lastly, steps should be taken to build stronger rural health communities that mobilize all types of human resources (e.g., patients and family caregivers) and institutions (e.g., educational, social, and faith-based) to both augment and support the contributions of health professionals.



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Quality Through Collaboration: The Future of Rural Health 4 Human Resources SUMMARY An adequate supply of properly educated health care professionals is critical to meeting the health needs of rural and frontier communities. Experientially based education programs should be enhanced to ensure that all health professionals master the core competencies necessary to provide high-quality care (i.e., provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics). Efforts should also be made to boost the supply of health professionals in rural areas. A multifaceted approach to the recruitment and retention of health professionals is needed, including interventions at every point along the rural workforce pipeline: (1) enhanced preparation of rural elementary and high school students to pursue health careers; (2) stronger commitment of health professions education programs to recruiting students from rural areas, educating and training students in rural areas, and adopting rural-appropriate curricula; and (3) stronger incentives for health professionals to seek and retain employment in rural areas. Lastly, steps should be taken to build stronger rural health communities that mobilize all types of human resources (e.g., patients and family caregivers) and institutions (e.g., educational, social, and faith-based) to both augment and support the contributions of health professionals.

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Quality Through Collaboration: The Future of Rural Health Human resources are critical to every rural community’s efforts to improve individual and population health. Human resources include health care professionals, both those in practice and those in training, as well as the population at large in the community. The recruitment and retention of an adequate supply of properly trained health care professionals are essential for the delivery of quality health care. Although advances in information and communications technology (ICT) hold promise for providing rural residents with remote access to many specialists and services (see Chapter 6), a good deal of health care is best provided locally. The provision of many essential health care services—preventive and primary care, surgical and hospital care, chronic care management, and emergency care—relies to varying degrees on the availability of health care professionals with the appropriate education and skills to provide care competently. For decades, rural and frontier communities have struggled to attract and retain an adequate supply of the various health care professionals that make up the rural health care team, including family physicians, nurse professionals, physician assistants, emergency care specialists, mental and behavioral health professionals, pharmacists, and dentists. (Appendix C provides detailed information on the availability of various types of health professionals in rural areas.) Some success has been achieved in attracting certain types of health care professionals, while shortages of others have grown worse. Demographic trends make it essential that greater efforts be made to address the health professional workforce needs of rural communities. Many rural communities are experiencing an increase in residents over age 65 as a result of the aging of the population and in-migration of retirees from the “baby boom” generation (see Appendix B). Unless steps are taken soon, there will likely be a widening gap between the available numbers of health care providers and the numbers required to meet the needs of rural populations. The aging of the population and the associated increase in persons with multiple chronic conditions also make it imperative that steps be taken soon to establish better methods of communication and information sharing among the providers in a community. There is no doubt that the health care professional workforce is important, but so, too, is the broader set of human resources in rural communities. As discussed in Chapter 2, to achieve significant improvements in health, rural communities will need to pursue initiatives aimed at improving both population health and the quality of the personal health care system. Rural residents and other community stakeholders (e.g., social service agencies, educational institutions, faith-based organizations) play a pivotal role at each

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Quality Through Collaboration: The Future of Rural Health of these levels in determining health care needs and outcomes. Of particular importance are the health-related knowledge and skills of a rural community’s population and the tools and supports available to individuals to manage their health needs. This chapter includes four sections. The first provides an overview of fundamental reforms in health professions education and training needed to improve quality of care and explains their particular relevance to rural communities. The second provides an overview of the points along the rural workforce pipeline and identifies a set of interventions that should be pursued to increase the supply and enhance the skill set of rural health professionals. The third describes various options for mobilizing a broader set of human resources—those of the population at large and those resident within other social institutions (e.g., social service agencies, educational institutions, faith-based organizations)—to improve health and health care in rural communities. The final section presents conclusions and recommendations. FUNDAMENTAL REFORMS TO IMPROVE QUALITY Fundamental changes within health professions education are needed to better prepare clinicians to respond to the population’s needs and address shortcomings in quality—changes that are important to both urban and rural communities. The focus of the health care needs of the American population has been shifting for several decades from acute illnesses to chronic conditions. The management of chronic conditions calls for a model of health care delivery that (1) actively engages patients and family caregivers and offers them educational, psychosocial, and other supports for the ongoing management of these conditions, and (2) provides coordinated care through multidisciplinary teams. In addition to the changing needs of the population, there has been an exponential increase in the science base that supports health care (IOM, 2001). Many of today’s quality shortcomings stem from a failure to provide clinicians with the educational and organizational supports required to remain current with the evidence base and apply the evidence appropriately to practice (DiCenso et al., 1998; Evers, 2001; Haynes, 2002; Jadad and Haynes, 1998; Lang, 1999; Mazurek, 2002). The Quality Chasm report (IOM, 2001) asserts that achieving the highest quality of care possible is predicated on both the redesign of systems of care and a workforce that is fully prepared to function in these new systems (IOM, 2001). To function in redesigned rural health care systems that consistently deliver quality care, health professionals will need to have knowledge and skills that have not historically been

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Quality Through Collaboration: The Future of Rural Health part of health professions and health management education, but are essential to moving the quality agenda forward in both rural health care environments and rural communities. Core Competencies for Health Professionals In 2002, the IOM convened a summit of leaders from the health professions, primarily medicine, nursing, allied health, and pharmacy, to identify changes in health professions education and training required to achieve the vision of high-quality care set forth in the Quality Chasm report. Participants at the summit identified five core competencies that all health professionals should possess (see Box 4-1). Educational programs at all levels (i.e., undergraduate, graduate, and continuing education) should focus greater attention on these core competencies. Although these competencies are relevant for clinicians in all geographic areas, the way they are operationalized by providers may be influenced by the characteristics of the practice setting, including rural versus urban. Substantial work will be required to ensure the consistent acquisition and application of these competencies across rural settings. BOX 4-1 Core Competencies for Health Professionals Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics SOURCE: IOM, 2003c. Provide Patient-Centered Care This competency requires knowing and respecting patients’ differences, values, preferences, and expressed needs. The focus is on shared decision making and care management. Research indicates that patients involved in care decisions and management have better health outcomes, lower costs, and higher functional status than those not thus involved (Bodenheimer et

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Quality Through Collaboration: The Future of Rural Health al., 2002a,b; Lorig et al., 1999). This competency also incorporates a focus on population health. To provide patient-centered care, clinicians must have cultural competency and familiarity with key facets of the lives and environments of rural residents. Because familiarity with many members of the community is common in rural areas, clinicians, from office nurses to pharmacists, are often knowledgeable about patients’ social, cultural, and family characteristics. Recent studies confirm a sizable proportion of minority patients report problems in communicating with clinicians of different ethnic and racial backgrounds, and as a result, do not fully understand the physician’s written instructions or follow medical advice (Collins et al., 2002; Cooper et al., 2003; IOM, 2003a). Similar problems likely arise when the “cultural divide” is one related to rural versus urban background. As discussed later in this chapter, many steps can and should be taken to enable and encourage rural residents to pursue health professions careers, and this is one strategy to enhance patient-centered care. However, for the foreseeable future, it is likely that rural health systems will rely on clinicians with many different cultural backgrounds, and from urban areas and foreign countries. This makes it particularly important that education and training programs, especially experiential, rural community-based programs, place sufficient emphasis on enhancing the cultural competency and communication skills of all providers. This competency is closely linked to one of the ten simple rules for the twenty-first century health care system set forth in the Quality Chasm report. This rule identifies the patient as the source of control, with care being customized based on patient needs and values. Since there is a lower proportion of individuals with formal education in rural communities (see Appendix B), patients and families may need more guidance and support to ensure understanding of their choices as they make decisions about their care and to maximize their ability to engage in self-management. Given the fairly well-defined composition of rural communities served by local health care clinicians, rural health care systems may be well positioned to take a population focus, including engaging the local community in determining its needs and preferences for health care services. Knowledge of what drives rural residents’ utilization of services, of community risk factors, and of health status and other population characteristics can inform customized illness prevention and health promotion efforts at the community level, as well as appropriate behavioral changes.

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Quality Through Collaboration: The Future of Rural Health Work in Interdisciplinary Teams This competency involves health professionals from varied disciplines who collaborate, communicate, and integrate care to ensure consistent, high quality. An interdisciplinary approach is especially relevant to rural health care given the higher frequency of chronic illness in rural versus urban populations (USAC, 2004). The involvement of a range of clinicians with varying knowledge, skills, and experience is particularly important to the ongoing management of patients with chronic conditions. In addition to care for chronic illness, an interdisciplinary team approach is important for the provision of acute care, such as when a patient in the immediate care of rural emergency medical technicians is transported to the emergency room of a rural or urban hospital. Acquiring this competency is also important for rural clinicians given that team approaches have been linked to key quality improvements, including greater concordance with complex treatment protocols for the chronically ill, decreased risk-adjusted lengths of stay in intensive care units, and impact on patient safety and reduction of medical errors (IOM, 2003c). One distinctive feature of many rural health care settings is the broader scope of practice for primary care providers and the greater use of midlevel professionals (e.g., nurse practitioners) and technicians (e.g., pharmacy and physical therapy technicians) (see Appendix C). In the area of mental health, for example, primary care physicians provide the majority of services (Hartley et al., 1999). When such services are provided by mental health professionals, rural areas often rely on social workers and psychiatric nurses, whereas urban areas tend to have a greater complement of psychiatrists and psychologists. In redesigned health systems, rural teams must have effective methods of providing supervision, expert consultation, and emergency backup to offer patients seamless care regardless of the setting or team member engaged with the patient at any given time. All team members must have strong communication skills and a clear understanding of each other’s roles and responsibilities. In rural settings, it is not uncommon for health care workers to know each other and to have worked together for years, a situation intensified by the markedly smaller number of clinicians and managers involved. Yet competency in team care requires much more than familiarity. It involves learning approaches to maximize collaborative work; ensuring that timely information reaches those who need it; and managing patient transitions across settings and over time, even when team members are in different physical locations. Because rural health care services frequently are based

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Quality Through Collaboration: The Future of Rural Health in a single organization—typically the local hospital—that provides an array of services from home health to outpatient to nursing home care, rural team members in many settings often have easier access to one another and closer communication as patients move across care sectors. When specialty or subspecialty care is involved, however, it is not uncommon for clinicians to be communicating with other providers located 50 or 100 miles away. Ensuring that all relevant information from the distant site accompanies the patient back to the rural community can be problematic, and open communication can be inhibited. Ensuring that team concepts and processes are employed under these circumstances may be more challenging. Employ Evidence-Based Practice Providing evidence-based care requires that clinicians be skilled in accessing the current knowledge base, including literature syntheses (e.g., Cochrane Collaboratives) and practice guidelines promulgated by professional organizations and other reputable sources (French, 1999; Grad et al., 2001; Rosswurm and Larrabee, 1999; Walshe and Rundall, 2001). This competency further requires that clinicians be able to integrate evidence with clinical expertise and patient values. As the science base has grown and the complexity of care has increased, it is apparent that applying science appropriately to practice for every patient requires carefully designed care processes. Indeed, this competency relates directly to another of the ten simple rules alluded to above: that decision making is evidence-based, with clinicians providing care and administrators facilitating system redesign on the basis of scientific knowledge. Prerequisite to this competency is having access to current evidence. Historically, this competency has been difficult to achieve for clinicians in many rural environments because of a lack of such access. Because they are often few in number, clinicians in rural areas can have difficulty obtaining coverage to attend regional or national educational conferences. Likewise, rural facilities have traditionally been beyond the scope of educational opportunities such as grand rounds and in-house presentations that are common to teaching hospitals and other entities. The availability of the Internet and web-based information from such sources as the Agency for Healthcare Research and Quality now gives the rural workforce virtually the same opportunities as their urban counterparts to access the latest information and ensure that their patients will receive services based on the most current evidence available. However, the applica-

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Quality Through Collaboration: The Future of Rural Health tion of some research to rural patients and settings can be problematic. Much of the quality research on clinical care and health care management, for example, has been done in tertiary care settings and may not reflect the structures and processes common to rural health care delivery. Furthermore, the application of evidence to practice in rural settings can be challenging given the time constraints of clinicians, the lack of clinical librarians, and the part-time status of some clinicians. Additionally, because of the low volume of patients seen in many rural facilities, it is not uncommon to find clinicians who must maintain current knowledge across a range of practice areas. Caring for individuals with health problems that present far less frequently in rural settings also poses a special challenge to the members of the health care team, who must ensure that they maintain their knowledge and proficiency in the context of rural resources and the relative lack of organizational support. Apply Quality Improvement All health care professionals should possess a basic knowledge of quality improvement theory and the ability to employ quality measurement and improvement tools in their practice, including measuring quality in terms of structure, process, and outcomes in relation to patient and community needs. Improving patient safety (i.e., reducing errors), for example, involves (1) developing a culture of safety in the health care system that encourages and rewards individual and organizational behavior directed at safety improvements, (2) establishing reporting and analysis systems to capture near misses and injuries and to conduct root-cause analyses to identify the factors that contributed to errors, and (3) redesigning care processes to reduce the likelihood of errors occurring and mitigate harm when they do occur (IOM, 2004d). This competency links to another of the ten simple rules: that safety is a system property whereby health professionals engage in system redesign efforts to prevent and mitigate errors and decrease resource waste. Rural areas have characteristics that make achieving this end different in some respects than in urban settings. In rural health settings, leadership in quality assurance and improvement efforts often rests with a senior clinician who is responsible for multiple tasks. This can represent a challenge given that quality improvement requires knowledge of the field, along with the ability to assess current practices and compare them with those of other providers and facilities, to design and implement process changes, and to incorporate

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Quality Through Collaboration: The Future of Rural Health safety design principles such as human factors-related training and standardization. In rural areas, information relevant to quality improvement may be accessed through networks of rural and/or urban facilities sharing such resources; through Quality Improvement Organizations (QIOs); or, in the case of critical access hospitals, the use of federal funds available through the Rural Hospital Flexibility Program. For example, sharing information across a number of geographically dispersed facilities in Montana allows the pooling and application of expertise and acquired knowledge. Furthermore, physicians in some rural communities in states such as North Dakota engage in peer review of the work of colleagues, not necessarily within their own facility, but in similar facilities across significant geographic distances. Increasingly, rural facilities are building such networks to pool limited resources and maximize access to expertise for quality improvement purposes, further demonstrating the high value of networking and collaboration among rural health organizations and with urban facilities. As mentioned earlier, the competency to apply quality improvement is linked to decreasing the waste of resources, including money, time, and ideas. While some may view rural health care facilities as efficient, even with such circumstances as fixed overhead and low service volume, waste can be identified in rural care processes. For example, when a patient is stabilized and subsequently transferred from a rural hospital emergency room to an urban hospital, it is not uncommon for laboratory and other tests to be repeated at the urban facility. Likewise, to meet internal rules and external requirements, multiple transfer forms are completed in many rural facilities as part of the transfer process. The competency to apply quality improvement encompasses the ability to address both overuse of services and inefficient redundancies. The focus of quality improvement and the processes by which it is implemented in rural facilities may differ from the urban case given the differences in organizational structure, processes, workforce, and patient mix. Consequently, applying the quality improvement literature in rural environments may require additional steps on the part of rural providers to ensure appropriateness, relevance, and success in implementation. One potential advantage of the application of quality improvement in rural settings is that while large facilities often adopt new practices on a unit-by-unit basis, the size of rural facilities may allow system-wide adoption to be accomplished more quickly and efficiently. Finally, if the rural workforce is to deliver high-quality care, it must be

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Quality Through Collaboration: The Future of Rural Health led by individuals and boards who want and expect innovation, understand the essential ingredients in improving quality, and ensure that the workforce has the time and the resources to acquire the necessary knowledge and skills. Infrastructure support is essential as well to assist providers in accessing and incorporating an ever-expanding knowledge and technology base. Utilize Informatics Building an ICT infrastructure to support care delivery is critical to achieving the six quality aims (see Chapter 6). ICT also links to another of the ten simple rules—that knowledge is shared and information flows freely. Elements of an ICT infrastructure for health care include electronic health records, clinical decision-support tools, and telehealth capabilities, with a focus on such areas as knowledge management, error reduction, and information acquisition. Such an ICT infrastructure has far-reaching implications for the way in which care is delivered and for the roles of health professionals and patients. With some exceptions, rural health care continues to be dominated by paper-based information. Yet given the established links that generally exist across a small set of health care providers within rural communities, there is great potential to automate those links and enable information to be readily shared. Health care professionals must appreciate the importance of ICT to delivering high-quality care and have the knowledge and skills to acquire ICT and use it effectively in their practices. This is particularly important in rural areas, where the typical practice setting is very small, and access to technical expertise in ICT is limited. Moreover, clinicians’ access to technology such as telemedicine and email can be challenging in communities that have limited infrastructure linking them to high-speed lines. These structural issues can limit access to services in rural communities that do not have the personnel to staff critical care units, radiologists available around the clock, or mental health care providers such as psychiatrists available in the immediate community. Programs to Provide the Core Competencies The five core competencies are relevant to health care professionals at all stages of their career—as students, recent graduates, and seasoned clinicians—and to a great extent are acquired through experiential learning programs. Such programs will need to be established at the community level

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Quality Through Collaboration: The Future of Rural Health and engage all providers in the community. Rural communities offer excellent opportunities to establish such programs for several reasons. First, they are generally less complex than urban environments because of their smaller size and scale. Second, the scarcity of providers in rural communities should facilitate collaboration. Third, as discussed in Chapter 3, in rural areas many quality measurement and improvement activities need to involve the entire community because individual practice settings have insufficient sample sizes and expertise to support those activities. The development of such experiential learning programs should proceed in tandem with the establishment of an ICT infrastructure (see Chapter 6). The Health Resources and Services Administration (HRSA) administers dozens of grant programs to increase the supply and enhance the training of health professionals, especially those willing to work in areas designated as having too few providers, as well as those who are members of an ethnic or racial minority group or who come from a disadvantaged background. Most but not all of these programs are authorized under Titles VII and VIII of the Public Health Service Act, and they are funded at a relatively modest level (approximately $289.5 million in fiscal year 2004) (BHPR, 2004d,e; HRSA, 2004a,b,c). Few target rural communities directly, so it is unclear the extent to which rural communities benefit. Several federal grant programs provide modest financial support for interdisciplinary training in rural communities. In the past decade, the Quentin Burdick Rural Program for Interdisciplinary Training has trained about 13,000 practicing clinicians, teachers, and students in 29 states through demonstration programs, with area health education centers often being the grantees in collaboration with other community-based organizations (BHPR, 2004d). In fiscal year 2003, the program awarded 23 grants for a total of $6.2 million. There are also a number of federal grant programs that support interdisciplinary training at specific sites, including HRSA’s Area Health Education Centers (often located in medical schools), Health Education and Training Centers in the southwestern border region ($4 million for 13 projects in fiscal year 2003), and Geriatric Education Centers ($15.6 million for 46 projects in fiscal year 2003) (BHPR, 2004a,b,c). A number of states also support interdisciplinary training programs (Buckwalter, 2004). These programs, especially the Quentin Burdick Rural Program for Interdisciplinary Training, provide a foundation upon which to build. Additional support will be required to accomplish the objective of providing experiential training in the five core competencies for all clinicians in rural areas.

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Quality Through Collaboration: The Future of Rural Health residents of a community give significance to health information and messages, shape perceptions of health and illness, and influence the use of the health care system. As discussed above, enhancements of precollegiate education aimed at ensuring an adequate pool of rural students prepared to pursue health professions careers will likely contribute to increased literacy and health literacy on the part of the general population. But greater emphasis on science and health education will not be enough. Raising population-wide literacy and health literacy will require much broader improvements in grade K through 12 education. Within the purview of the health system, a great deal can be done to improve health literacy. As recommended in an earlier IOM report (IOM, 2004b), health care providers, purchasers, and other stakeholders should improve their health-related communications by engaging consumers in the development of health messages, exploring creative approaches to the communication of health information using printed and electronic materials and media, and establishing methods for creating health information content in appropriate and clear language. The report also recommends that cultural and linguistic competency of health care providers be included as an essential measure of the quality of care, and that public and private oversight, accreditation, and certification programs incorporate health literacy into their standards for health care professionals and organizations. As discussed in Chapter 6, expansion of access to the Internet and establishment of a National Health Information Infrastructure open up many opportunities to enhance health communication and provide a variety of other supports to residents of rural communities. Indeed, the focus of informatics is shifting from provider-oriented to consumer-oriented information and decision support (see Figure 4-2). This shift raises key issues that will need to be addressed in the coming years: How best to guide consumers to reliable and understandable sources of clinical and other information (e.g., scientific evidence, practice guidelines, best practices). What ICT tools will be most useful to consumers in managing their own health (e.g., personal health records, web-based support groups). What steps can be taken now to better prepare the lay public to interact with and derive the greatest benefit from the ICT resources that are steadily becoming available in most communities.

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Quality Through Collaboration: The Future of Rural Health FIGURE 4-2 The focus of traditional medical informatics is shifting from health professionals to consumers. SOURCE: Eysenbach, 2000. Now is the time for all communities, both rural and urban, to begin preparing for the dramatic changes in health and health care that are likely to occur in the coming decade. As they go down this road, communities will be able to learn a great deal from each other, as well as from efforts under way in other countries (Detmer et al., 2003). CONCLUSIONS AND RECOMMENDATIONS Human resources—both health care professionals and the population at large in the community—are critical assets in every rural community’s efforts to improve both individual and population health. The current health care workforce, including that in rural areas, is poorly prepared to address the quality challenge. Most formal educational programs for health professionals place limited emphasis on the core competencies identified by the IOM (2003c). Existing workforce training programs using supportive infor-

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Quality Through Collaboration: The Future of Rural Health mation technology should be strengthened to assist health care professionals already in practice in mastering these competencies. Recommendation 3. Congress should provide appropriate resources to the Health Resources and Services Administration to expand experientially based workforce training programs in rural areas to ensure that all health care professionals master the core competencies of providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement, and utilizing informatics. These competencies are relevant to the many discipline-specific and multidisciplinary programs supported under Titles VII and VIII of the Social Security Act. There are many opportunities to redesign existing workforce training programs in ways that will support rural communities in their efforts to improve the quality of health care and enhance population health: More stable and generous funding should be provided for the Quentin Burdick Program to conduct demonstrations in several rural communities. These demonstrations should provide for (1) the training of leadership teams to mobilize community resources, (2) communitywide health literacy programs, and (3) interdisciplinary health professions education in the core competencies essential to improving quality. Workforce programs such as HRSA’s Area Health Education Centers, Health Education and Training Centers, and Geriatric Education Centers should explicitly target rural localities, and broaden their scope beyond physician supply to include midlevel providers in specialties in short supply in rural areas (e.g., mental health and substance abuse and emergency care). Workforce programs that recruit students from minority and underserved communities for health professions careers in rural communities—such as the Health Careers Opportunity Program, HRSA’s Centers of Excellence program, scholarship and loan repayment programs for disadvantaged students, and such programs offered by IHS—should expand their recruitment and placement efforts in rural communities. In expanding experientially based workforce recruitment and training programs, the federal government should place particular emphasis on the types of health professionals that are in very short supply and on the geographic areas experiencing the greatest difficulty in recruitment and reten-

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Quality Through Collaboration: The Future of Rural Health tion. Current workforce programs are hampered by a lack of data and information to target resources effectively. Key Finding 3. To target workforce training programs most effectively, federal, state, and local governments need better information on the current supply and types of health professionals. Data that would be particularly useful include the numbers of providers and provider hours of clinical practice, practice specialties, and sites of service. Financial and policy incentives at the federal and state levels could be put in place to facilitate the gathering, analysis, and retention of health professions workforce data that are comparable across states. Enhancing experientially based workforce training programs is an important first step, but it will not be enough. Fundamental change in health professions education programs will be needed to produce an adequate supply of properly educated health care professionals for rural and frontier communities. A multifaceted approach to the recruitment and retention of health professionals in rural areas is needed, including interventions at every point along the rural workforce pipeline: (1) enhanced preparation of rural elementary and high school students to pursue health careers; (2) stronger commitment of health professions education programs to recruiting students from rural areas, educating and training students in those areas, and adopting rural-appropriate curricula; and (3) a variety of strong incentives for health professionals to seek and retain employment in rural communities. To achieve the goal of an adequate and sustained supply of health care providers in rural areas, it will be necessary to undertake interventions at all of these points and to do so in a coordinated fashion. Enhancements to the basic curriculum, particularly the science curriculum, for middle and high school students are needed to better prepare rural students for careers in the health professions. HRSA’s Office of Rural Health Policy could work collaboratively with the various federal agencies (e.g., Bureau of Health Professions, Department of Education, Bureau of Indian Affairs, and IHS), professional associations, and rural constituencies to identify enhancements to the basic curriculum, particularly the science curriculum, for middle and high school students that would better prepare them for rural careers in the health professions. A rural health professions mentoring program might be established to expose rural students to potential careers in health care. Changes are also needed in health professions education programs. Greater effort must be made to recruit students from rural areas, to locate a

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Quality Through Collaboration: The Future of Rural Health meaningful portion of the formal educational experience in rural settings, and to develop education programs that are relevant to rural practice. Recommendation 4. Schools of medicine, dentistry, nursing, allied health, and public health and programs in mental and behavioral health should: Work collaboratively to establish outreach programs to rural areas to attract qualified applicants. Locate a meaningful portion of the educational experience in rural communities. Universities and 4-year colleges should expand distance learning programs and/or pursue formal arrangements with community and other colleges, including tribal and traditionally African American colleges, located in rural areas to extend the array of rural-based education options while encouraging students to pursue higher levels of education. Make greater effort to recruit faculty with experience in rural practice, and develop rural-relevant curricula addressing areas that are key to improving health and health care, including the five core competencies (i.e., providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement, and utilizing informatics), the fundamentals of population health, and leadership skills. Develop rural training tracks and fellowships that (1) provide students with rotations in rural provider sites; (2) emphasize primary care practice; and (3) provide cross-training in key areas of shortage in rural communities, such as emergency and trauma care, mental health, and obstetrics. Furthermore, the federal government should provide financial incentives for residency training programs to provide rural tracks by linking some portion of the graduate medical education payments under Medicare to achievement of this goal. The residents of rural communities also have a key role to play in improving population health. Residents can contribute to improving their own health and that of others by pursuing healthy behaviors and complying with treatment regimens, assuming appropriate caregiving roles for family members and neighbors, and volunteering for community health improvement efforts. In many rural populations, low levels of health literacy (the degree to which individuals have the capacity to obtain, process, and understand basic health information) currently hamper efforts to engage residents in health-

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