Quality Through Collaboration The Future of Rural Health (2005) / Chapter Skim
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4 Human Resources
4 Human Resources
Pages 78-118
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From page 78... ...
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.
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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.
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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.
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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.
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From page 82... ...
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.
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. 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.
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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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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.
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From page 86... ...
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.
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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.
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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)
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Internet-based educational opportunities for health professionals have expanded greatly in recent years, as has the technology for interactive distance learning. The committee does not view distance education programs as a substitute for community-based experiential training programs, but does think distance education should be explored as a way to help health professionals retain and build upon the core competencies initially acquired through the latter programs (although it should be noted that some state licensure programs limit the use of distance education in satisfying continuing medical education requirements [AMA, 2002]
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90 rural Sustain the workforce to areas rural Encourage students seek employment in rural Use appropriate curricula rural Locate education and training programs in areas rural pipeline. Recruit students from areas workforce 2002.
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For students who choose not to enroll in health professions training, such exposure contributes to increased health literacy and lays the groundwork for local residents to become more engaged and informed participants in health promotion and health care delivery in their communities. Over the last two decades, a great deal of attention has been focused on enhancing science education in grades K through 12 (Hart et al., 2003; NRC, 1996, 2002, 2003)
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From page 92... ...
An important aspect of preparing and recruiting future health professionals from rural communities is creating opportunities for members of minority and disadvantaged populations, such as American Indians, Alaska Natives, and African, Hispanic, and Asian Americans, who may be overrepresented in rural versus urban locales and underrepresented among rural
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From page 93... ...
In addition, additional study should be undertaken to better understand the relative contribution of various types of factors, both quantitative and qualitative, in identifying prospective candidates likely to complete the educational program successfully and to pursue careers in rural areas. Following is a brief discussion of current formal education programs for generalist physicians, nurses, physician assistants, emergency care professionals, dentists, pharmacists, mental and behavioral health care professionals, health administrators, and public health professionals as they pertain to building the rural health care workforce.
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, which places 8 students annually at clinical training sites in the Upper Peninsula; the Rural Medical Education Program (University of Illinois College of Medicine at Rockford) , which admits up to 15 students each year for training that includes early and sustained participation in ambulatory primary care at rural sites and rural preceptorships; the University of North Dakota, which places 7 students in the third year of medical school in a 7month rural experience known as ROME (Rural Opportunities in Medical Education)
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This committee concurs and, specifically, encourages Congress and the administration to be particularly attentive to the needs of rural communities when pursuing incremental reform. In addition to a commitment to training more generalists for rural practice, there must be a commitment to meeting the needs of rural populations for specialty care.
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. For these professionals, as for physicians, characteristics associated with success in rural practice include a rural background or upbringing and health professions training in a rural environment (Hart et al., 2002)
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The program features web-based updates on work progress and communication with other students, faculty, and community residents. Emergency Care Professionals There are two groups of emergency medical services (EMS)
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. Training more specialist physicians in emergency medicine oriented toward rural practice -- through new residency programs and clinical training sites -- may be less feasible than expanding the content of family medicine or primary care residencies to encompass cross-training in emergency care.
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. Meeting the pharmacy needs of rural areas through training will involve collaboration between schools of pharmacy and rural areas, given that, as with other health professions, students from rural areas are more likely to choose rural practice (Scott et al., 1992)
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The majority of programs are associated with health professions schools (e.g., public health, medicine, nursing, allied health) , providing opportuni
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Public Health Professionals Several IOM reports have pointed to the need for significant improvement in the U.S. public health infrastructure in order to better serve the needs of population health (IOM, 2001, 2003b, 2004b)
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. Federal Title VII and VIII health professions training programs have a broader scope than NHSC, encompassing the training of physicians, nurses, dentists, pharmacists, and public health and allied health professionals (NRHA, 2004)
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Lack of data on the numbers of health professionals in rural areas hampers the process of designation and assignment, however, as well as the efficient use of scarce resources. In the case of mental health, for example, states may count either psychiatrists only, or other mental health specialists as well (i.e., social workers, clinical psychologists, clinical social workers, and therapists)
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In an effort to address the heavy workload and on-call burden of rural clinicians, some rural communities take advantage of either locum tenums programs, which offer respite and backup for providers in remote areas, or temporary contracts with provider groups (an alternative to locum tenums often used by hospitals in need of emergency medical services backup) (Williams et al., 2001)
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State licensure and scope-of-practice statutes can impede or facilitate the flow of health professionals into rural areas by influencing both the roles played by different types of health professionals and the financial playing field (i.e., eligibility for reimbursement of certain services under public and private insurance programs)
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EMS programs in Montana and New Mexico have used remote continuing education to retain rural health professionals while expanding the scope of practice for both licensed providers and paraprofessionals. For example, New Mexico's Red River Project has trained EMTs in triage and referral to primary care providers (Gamm et al., 2003; NRHA, 1997)
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Health literacy skills are needed to read and understand health information (e.g., immunization schedules, drug inserts, hospital discharge instructions) ; to calculate the timing and dosage of medicines; to evaluate and make decisions about treatment options and participation in clinical trials; to understand and give consent (e.g., complete an advance directive)
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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)
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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)
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. · Workforce programs that recruit students from minority and underserved communities for health professions careers in rural communities -- such as the Health Careers Opportunity Program, HRSAs 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.
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From page 111... ...
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.
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From page 112... ...
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.
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52 60. BHPR (Bureau of Health Professions)
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San Francisco, CA: The Center for the Health Professions. French P
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Health Professions Education and Training Funding Opportunities. [Online]
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Joint Commission. Journal on Quality Improvement 255(10)
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2004. Policy Brief: Health Professions: Title VII of the Public Health Service Act Reauthorization.
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2000. Healthy People 2010: Understanding and Improving Health.
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