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.
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
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
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.
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
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.
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
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-
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
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
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.
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
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.
Additionally, organizations that focus on health care for rural communities, such as the National Rural Health Association, the small and rural hospitals section of the American Hospital Association, the State Offices of Rural Health, and the federally funded Rural Assistance Center (http://www.raconline.org) could serve as information conduits to help providers acquire the core competencies. Organizations with a quality focus, such as the Institute for Safe Medication Practices, the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, and others, could target efforts to rural audiences. As discussed in Chapter 3, QIOs might provide greater technical assistance to rural providers in acquiring quality improvement knowledge and techniques. Lastly, it is important to recognize that educational supports can be provided through distance learning programs. 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]). The committee recognizes that there are advantages and disadvantages to distance learning, but does encourage states and other regulatory bodies to periodically re-evaluate this option as distance education programs and technologies evolve.
ENHANCING THE RURAL HEALTH PROFESSIONS WORKFORCE
The model for achieving greater numbers of rural clinicians is often conceptualized in terms of a pipeline, with each point along the pipeline playing an essential part in achieving the ultimate goal of increasing the size of the rural workforce and its capacity to provide high-quality health care (see Figure 4-1). The points shown in Figure 4-1 can be aggregated into three broad areas: (1) attracting rural students to health careers, (2) providing formal education programs, and (3) recruiting and retraining trained health professionals in rural areas. The IOM committee believes there are opportunities to make improvements in each of these links that will enhance the supply of health professionals in rural areas and to improve their competency in the five core areas discussed above.
Measures to Attract Rural Students to Health Careers
There is evidence to indicate that people from rural communities who become health professionals are more likely to choose to practice in rural areas after completing their formal education and to remain in rural practice for longer periods of time then their nonrural counterparts (Rabinowtiz et al., 2001). Measures to attract rural students to health careers involve enrichment of schooling for precollegiate students, ensuring that basic science is part of the curriculum and that students have positive exposure to role models and career paths in rural health care delivery. 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). In 1996, the Department of Education promulgated National Science Education Standards to serve as guidelines for states and local districts in developing their own, more specific standards, curriculum, and implementation processes. Many of the nation’s schools are enhancing their science curricula. Responses to a 2000 survey indicated that 46 states had developed new science content standards, but only 4 states required 4 science credits for graduation (compared with 18 states that required 2 credits and 16 that required 1.5–3.5 credits) (NRC, 2003). By the time of graduation, 95 percent of students had completed a biology course, 54 percent in chemistry (versus 45 percent in 1990) and 23 percent in physics (versus 20 percent in 1990). Enrollment of African Americans and Hispanics in higher-level classes continued to lag behind that of Caucasians and Asians across the board. Results specific to rural and urban areas are not available.
There are a handful of innovative programs that expose elementary and high school students from rural areas to health professions information and role models. These include programs that provide volunteer ambulance corps assignments for high school and elementary students from rural areas (New York); send teams of health professions students to teach health education and discuss careers with rural adolescents at 4-H summer camps (Tennessee); enroll minority and lower-income high school students in the Health Sciences and Technology Academy; and provide summer health careers education through local science clubs (West Virginia) (Gamm et al., 2002). The Academy also supports science teachers by helping them learn better teaching skills to maintain their students’ interest in science and math. Formal
evaluation of these programs is needed to assess their success in recruiting rural students into the health professions.
Formal Education Programs
The supply of health care professionals is influenced by both the capacity of health professions education programs and the structure and content of these programs. Studies of the geographic distribution of health professionals confirm that as their overall supply increases, so, too, does the diffusion of clinicians into rural areas. For example, early studies of physician diffusion found that as the supply of physicians grew during the 1970s, many chose to practice in rural areas, so that by 1979, nearly every small town (with a population of more than 2,500) had ready access to a physician (Newhouse et al., 1982). This finding has been corroborated by recent studies showing that as the supply of physicians doubled between 1979 and 1999, geographic access continued to improve (Rosenthal et al., 2003).
It is important to note, however, that the relationship between increased supply and greater geographic distribution is, to a great extent, specialty specific. That is, as the supply of physicians of a particular specialty increases, physicians of that specialty are more likely to seek practice in rural areas. This is an important caveat for rural areas. As discussed above, rural areas rely to a great extent on family physicians, and this is the one specialty that experienced a steady and progressive decline in numbers from 1980 through 1999 (Biola et al., 2003).
The structure and content of health professions education programs also influence a clinician’s likelihood of choosing rural practice and preparedness to provide high-quality care in rural settings. First, as noted above, recruitment of qualified students from rural communities influences the choice of practice setting. Second, the likelihood of health professionals choosing to practice in rural areas is also increased if they are able to remain in rural areas while obtaining some or all of their professional education (Hart et al., 2002). Third, to adequately prepare health professionals to practice in rural areas, education programs must recruit faculty with rural practice experience and develop appropriate curricula.
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
providers. As noted earlier, HRSA administers a number of programs aimed at recruiting students from such backgrounds. These include loan repayment and scholarship programs, as well as grant programs that support recruitment and training of such students and future faculty at schools and affiliated training programs (BHPR, 2004b). Additionally, the Indian Health Service (IHS) offers a range of programs across the spectrum of health professions, encompassing undergraduate preparatory training, externships, and health professions scholarship and loan repayment, to students who are members of federally recognized tribes, and gives hiring preference to tribe members (BHPR, 2004b).
These programs can be further augmented with improvement in the policies and practices that govern the admissions processes of health professions educational programs as recommended in the 2004 IOM report, In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. This earlier IOM report recommends that:
Admissions should be based on a comprehensive review of each applicant. Such attributes include, but are not limited to, applicants’ race or ethnicity, socioeconomic background, cross-cultural experience, life choices, multilingual abilities, interpersonal skills, cultural competence, leadership qualities, barriers the applicant has overcome, and other attributes that reflect the institutional mission. Admissions models should balance quantitative data (i.e., prior grades and standardized test scores) with these qualitative characteristics (IOM, 2004c, p. 85).
Health professions educational programs are encouraged to examine their admissions practices to ensure that the criteria for admission are well balanced and consistent with the program’s overall objectives. 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.
For physicians, two factors are strongly predictive of a future career in rural health: a rural background and plans to enter family medicine
(Rabinowitz and Taylor, 2004). With regard to medical school training, other important predictive factors include the commitment of the medical school to rural practice (public schools in rural states are more likely to have such a commitment than are private research schools in urban areas), provision of training in family medicine, experienced faculty role models or mentors with a rural focus, required rural experiential learning at different stages of training, and the presence of advisors to assist with the transition to a rural residency (Hart et al., 2002; Hartley et al., 1999; WHA, 2004).
Medical schools that make a strong commitment to educating physicians for rural practice have quite successful track records. Jefferson Medical College’s Physician Shortage Area Program (PSAP) in Philadelphia, which recruits and provides financial assistance to rural students and offers focused training in family medicine (mentoring, rural clerkships, and preceptorships), produces graduates that are more than 8.5 times as likely to work in rural family medicine than Jefferson’s non-PSAP graduates (Liederman and Morefield, 2003; Rabinowitz and Taylor, 2004). Other examples include the Rural Physician Program (Michigan State University), 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 7-month rural experience known as ROME (Rural Opportunities in Medical Education); and the Rural/Underserved Opportunities program, which offers clinical placement and clerkships at rural sites in Spokane, Washington, and Boise, Idaho (WHA, 2004). It may be noted that osteopaths are overrepresented among all physicians in rural areas, reflecting the orientation of their training toward primary care of underserved groups and rural clinical sites for training (Tooke-Rawlins, 2000).
The factors noted above as predictive of a future career in rural health are not the norm in residency and other postgraduate training. Most residency training takes place in urban teaching hospitals, and the majority of public (federal and state) financing of residency training through Medicare and Medicaid graduate medical education (GME) programs flows to hospitals in urban settings. In 1998, only about 3 percent of acute care hospitals in nonmetropolitan counties (70 hospitals) participated in Medicare GME, compared with almost 40 percent of hospitals in metropolitan areas (NRHA, 2003). The committee concurs with others that the nearly $14 billion in pub-
lic funds spent annually ($6 billion through Medicare, $4 billion through Medicaid, plus more than $4 billion in state support to allopathic medical schools) to educate 22,000 physicians could be better targeted to achieve rural workforce goals (Myers, 2000; NRHA, 2003).
An earlier IOM committee examined alternatives for better aligning public financing of GME with the attainment of health care workforce goals (IOM, 2004a). Two options were considered:
Incremental change in existing payment programs—For example, the Medicare program’s direct and indirect GME programs could be tied more closely to the training of family physicians (who are more likely to practice in rural settings) or to the training of residents in rural hospitals. This approach maintains a link with an entitlement program (i.e., “automatic” funding), but has the disadvantage of trying to achieve workforce goals through a payment program established with other objectives in mind.
Fundamental change—For example, health workforce subsidization might be removed from the Medicare payment program and replaced with a separate program designed specifically to achieve public policy goals. In theory, this approach would allow for the setting of national workforce goals and the structuring of a financing program to meet those goals, while one of the major disadvantages is that medical education would have to compete with other budget priorities in the appropriations process.
The earlier IOM committee concluded that it is unlikely that an entirely new funding source would be created and that the best course would be to pursue incremental change in existing payment programs. 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. To some extent, specialty needs can be met through cross-training of generalists. For example, family physicians and general surgeons can receive subspecialty training in emergency medicine (Williams et al., 2001). Likewise, pediatricians can be cross-trained to provide dental services, as is the case in one West Virginia community (Fos and Hutchison, 2003; Gordon, 2004). The numbers of certain types of specialists, such as psychiatrists, might be increased by establishing residency programs for those specialties with rotations in rural settings (Hartley et al., 1999). The
creation of networks linking specialist physicians serving rural areas with those in urban settings is also an important element of building the health infrastructure in a way that can better support both physicians and patients.
The rubric of nursing encompasses a variety of health professionals, from nursing assistants and licensed practical nurses with less than an associate’s degree, to registered nurses with associate’s and bachelor’s degrees, to advanced practice nurses with master’s- or doctoral-level training and state or national certification (such as clinical nurse specialists, practitioners, certified nurse midwives, and certified registered nurse anesthetists) (IOM, 2003d). For these professionals, as for physicians, characteristics associated with success in rural practice include a rural background or up-bringing and health professions training in a rural environment (Hart et al., 2002).
An example of an innovative program for training nurse professionals is the University of Iowa’s Registered Nurse-Bachelor of Science in Nursing Satellite Program, which trains rural students in their community of residence rather than requiring that they relocate to urban areas for schooling (Buckwalter, 2004). This program involves partnerships with community colleges, private health care agencies in Iowa and nearby states, and the University of Iowa’s Colleges of Nursing and Pharmacy, and uses distance learning and mentoring faculty.
Compared with nurse practitioners, physician assistants are trained in a more diverse range of settings, from medical schools and schools of allied health to community colleges and the military (Hooker, 2002). Federal (Title VII) and many state scholarship and loan forgiveness programs serve as incentives to recruit physician assistants to rural communities (see the section below on recruitment and retention). Yet while a greater proportion of physician assistants practice in rural areas relative to the proportion of the total physician population, there is a trend toward choosing urban practice locations among physician assistants (Baer and Smith, 1999). In recent years, two innovative training programs for physician assistants have added rural curricula and place-based, experiential training through the use of web-based distance education and local clinical mentors:
Since 1994, the Partnerships for Training Program, sponsored by The Robert Wood Johnson Foundation, has supported web-based distance education and clinical preceptorships based at satellite campuses in underserved areas (rural and urban) for physician assistant students (Johnson, 2002). As of 2002, 450 students had graduated, with at least 70 percent practicing in their communities.
In the late 1990s, the College of Health Sciences in Roanoke, Virginia, which graduates many of the baccalaureate-level health providers in the region (rural central Appalachia), added a community focus and web-based management of student clinical participation to its new physician assistant training program (Dezendorf and Scott, 2001). During their second year of training, students participate in month-long community health clinical rotations in two small Virginia towns, completing distance coursework during nights and weekends, and spending 2 days per week of clinical activity supervised by a physician with rural expertise and 3 days per week directly participating in a community health project. 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) providers: prehospital providers and hospital-based teams. Prehospital EMS providers include first responders, ambulance attendants and drivers, and emergency care technicians with basic, intermediate, or paramedic training (Rural EMS Initiative, 2000). The level of certification of EMS providers in rural areas varies considerably, such that a responding team in one area may have only basic emergency medical technicians (EMTs) available, while that in another area may include a paramedic, regardless of the health needs of the patient. In rural areas, many prehospital EMS providers are volunteers. Recent years have seen some efforts to make formal EMS training more accessible to rural providers. To address rural concerns that the typical 2-year length of training for paramedics discourages local enrollees from seeking advanced training, the State of California has implemented modular or discrete instructional units that are flexible to accommodate the schedules of volunteers (Franks et al., 2004). ICT-based distance learning has been demonstrated to be comparable to on-site classroom training and can be used for either initial training or continuing education, with the advantage of keeping EMS staff in the field (Franks et al., 2004). Such training also enhances the future
rural labor pool, for many volunteer technicians use their EMS experience as a stepping stone to education and work in other health care careers or in hospital or clinic settings (Franks et al., 2004).
Staffing hospital-based EMS services is also challenging. The need for 24-hour availability and the low volume of patients make it difficult for rural hospitals to hire specialists in emergency medicine and muster the financial resources to adequately support an EMS system (Moorhead et al., 2002; Rawlinson and Crews, 2003).
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. This cross-training could include certification of subspecialty training (in advanced cardiac life support, advanced trauma life support, and advanced pediatric life support) and training in interdisciplinary collaboration with the nurse professionals and physician assistants who make up a sizable proportion of the EMS workforce (Williams et al., 2001).
There is also a need to train emergency medicine physicians in urban areas that are adjacent to rural areas to provide support and backup for all types of clinicians in rural areas who must deal with emergency care needs. As discussed in Chapter 6, ICT is opening up many opportunities for enhanced collaboration between rural and urban areas.
Both IHS and HRSA offer a variety of scholarship and loan repayment programs targeting dentists and dental hygienists. These programs include support for postgraduate residencies and interdisciplinary training, as well as for training of ethnic and racial minority group members underrepresented in the workforce, although the support for these programs is relatively modest (NACRHHS, 2004). There are a number of innovative education programs aimed at increasing the supply of dentists and dental hygienists:
Nebraska has created a Midwest consortium for dental student education and financing that recruits from rural areas of Nebraska, South Dakota, Kansas, and Wyoming (Gordon, 2004).
The University of Colorado School of Dentistry includes a 6- to 18-week clinical rotation in a rural community both to provide rural residents
with access to care and to increase the likelihood that students will choose a rural practice location (Gordon, 2004).
A program in West Virginia provides pediatricians and school nurses with cross-training in dental care so they can deliver oral health screening and treatment services (Fos and Hutchison, 2003; Gordon, 2004).
After nurses and physicians, pharmacists are the third-largest group of health professionals (196,000 active in the United States in 2000) (Hart et al., 2002; HRSA, 2000; USDHHS, 2000). In recent years, the roles and expected functions of pharmacists have expanded as a result of many factors, including the increased complexity of drug prescribing and management due to the greater numbers of pharmacological agents, and concerns about medication safety, especially in light of the sizable numbers of people being treated with complex, multifaceted medication regimens. A longer period of training for pharmacists to earn a doctorate is now the norm, and postgraduate residencies are common (Cooksey et al., 2002). One survey of retail pharmacists in three rural states (Minnesota, North Dakota, and South Dakota) found that 95 percent had a bachelor’s degree (Casey et al., 2001).
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). The enhanced role of pharmacists beyond the simple dispensing of prescriptions requires not only new and different training than in the past, but also increased cross-training with other health care students to facilitate interdisciplinary team work, including telesupervision by pharmacists of pharmacy technicians working in remote locations, or pharmacist supervision of nurses performing pharmacy functions in small hospitals and nursing homes (Casey et al., 2001; Cooksey et al., 2002).
Mental and Behavioral Health Care Professionals
The bulk of mental and behavioral health services in rural areas are delivered by generalist physicians (Hartley et al., 1999). The specialists that provide these services, including psychiatrists (specialist physicians), clinical psychologists, counselors, social workers, and therapists with masters-level training are all in short supply in rural areas (Ivey et al., 1998).
Meeting the needs of rural communities for mental and behavioral health services will likely require a multifaceted approach. Cross-training of generalist physicians at rural training sites to facilitate screening, diagnosis, and referrals for mental health care would extend access to appropriate care in rural areas. Rural-focused residency programs in psychiatry might be developed for specialist physicians as well. Another option is to train more midlevel clinicians to provide mental and behavioral health services. For example, some success has been achieved in training advanced practice psychiatric nurses as either clinical nurse specialists (oriented toward psychotherapy) or psychiatric nurse practitioners (oriented toward the physiological bases of disease and case management). Nine rural states currently have degree programs (master’s or doctoral) in advanced practice psychiatric nursing, and the curricula of these programs target the identification and treatment of the chronically mentally ill (Hartley et al., 2004). On the other hand, efforts to fill the need for mental health providers through expanded use of psychologists with master’s degrees have encountered opposition from professional leadership within the field of psychology (see the discussion below of licensure and scope of practice).
Few health administration programs train their students explicitly for careers in rural areas. Traditionally, many rural health administrators have backgrounds in clinical or technical fields and have learned management skills on the job (Robertson and Cockley, 2004). Competencies recently identified for rural health administration students highlight facility in adapting conventional management approaches to rural needs for health care (given the older age profile and specific health concerns of rural residents), an understanding of reimbursement mechanisms (in light of the greater reliance on public payers), and expertise in managing multidisciplinary teams and evaluating small organizations (to address the broad range of duties typically carried out by small numbers of staff as compared with urban sites) (Robertson and Cockley, 2004).
A recent survey of health administration programs sheds light on some of the opportunities to incorporate a rural focus into the curricula of master’s-level programs (Reed and Hawkins, 2001). Over two-thirds of health administration programs are located in public institutions, where state legislatures could provide funding or other incentives for targeted rural training. The majority of programs are associated with health professions schools (e.g., public health, medicine, nursing, allied health), providing opportuni-
ties for cross-training and interdisciplinary approaches important to team work. To increase rural enrollment through place-based learning, more than a third have distance coursework, and nine offer distance degrees. Eighty percent require field experience (an average of 16 weeks) as part of their program.
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). A competently trained workforce is an essential element of the public health infrastructure. The public health workforce at the federal, state, and local levels must be prepared to meet an array of needs, such as providing community health education and information dissemination, ensuring health-related environmental safety, and responding to community emergencies (IOM, 2003b; NACRHHS, 2000). In 2001, the Centers for Disease Control and Prevention (CDC) found that 80 percent of the existing public health workforce lacked any formal training (an exception to this rule may be nurses). As many rural areas are not near an educational institution or do not have a well-developed public health program, most local community public health employees have had to learn on the job (NACRHHS, 2000). This gap seriously compromises a community’s ability to engage in surveillance activities necessary to prevent disease and maintain the health of the population.
Based on the findings of the 2001 survey, the CDC has called for public health departments to recruit and train new personnel. An earlier IOM committee recommended that such training programs take advantage of online education and interactive distance learning models to expand the education base (IOM, 2003b). Rural communities could establish innovative partnerships among local community colleges, schools of medicine and nursing, and public health departments to support educational requirements and lifelong learning (NACRHHS, 2000). These educational systems might be founded on the competency sets identified by the IOM (2003b):
Core—basic skills needed to perform the essential functions of public health
Function-specific—leadership, management, supervisory, support staff
Discipline-specific—community dentistry, other professionals or technical specialists
Subject-specific—maternal and child health, vaccine-preventable disease, cancer, chronic diseases
Workplace basics (required of all personnel)—literacy, writing and presentation skills, and computer literacy
In addition, ensuring a public health workforce requires monitoring workforce composition and future needs and developing curricula to meet these needs, implementing incentives to promote population health practices, conducting and supporting evaluation and research of population health, and sustaining financial support for learning systems (IOM, 2003b).
Recruitment and Retention
The health care workforce of rural communities is dependent on the ability to both recruit and retain trained health professionals. The primary focus of federal and state policy has been on recruitment, with much less emphasis on retention.
HRSA and 41 states (1996 data) sponsor both loan repayment and scholarship programs that bring hundreds of new health professionals to rural areas under multiyear service commitments (Hart et al., 2002). The National Health Service Corps (NHSC) is perhaps the best recognized of these programs, placing primary care providers, dentists, and mental health providers (both physicians and nonphysicians) in designated health professions shortage areas, often at federally supported clinics. NHSC has yet to yield a predictable supply of physicians for rural areas because enrollment depends on the numbers of graduating students with an interest in primary care and because medical school debt places strong financial pressure on graduates (Mueller, 2002). 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).
States and regions also facilitate rural placement using recruitment databases, such as the Iowa Health Professions Inventory; the Southern Rural Access Program, which recruits primary care providers for 8 southern states; and the National Rural Recruitment and Retention Network, in which 37 states participate (Gamm et al., 2003; WHA, 2004). Federally designated
shortage areas (including health professions shortage areas for primary health care, dental care, and mental health, and medically underserved areas) are eligible to offer both federal and state scholarship and loan repayments, as well as to participate in related HRSA workforce programs including NHSC. 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), in proposing that a county or locality be designated as a shortage area. Because few data are available on the numbers of nonpsychiatrist specialists actually involved in clinical practice and their hours, their specialties, and their practice sites, many states opt to rely on existing information on the number of psychiatrists—typically few or none in rural communities. The potential capacity of nonpsychiatrists may be underestimated as a result, and thus it becomes difficult or impossible to target behavioral health resources appropriately to those areas most in need.
International medical graduates (IMGs) are another source of physicians for many rural areas. Nationally, IMGs make up almost one-quarter of the nation’s supply of physicians actively involved in patient care in both urban and rural areas (2001 data, as cited in Hart et al., 2002). Despite potential mismatches between the skills of IMGs (who are often subspecialty trained in urban research-affiliated settings) and local needs for primary care, as well as a retention rate of about 50 percent after 3 years (the length of the typical service obligation), IMGs are commonly found in rural critical access hospitals in counties defined as persistently poor and in some of the most remote and smallest hospitals (Hagopian et al., 2004; WHA, 2004). IMGs are also hired by hospitals as specialists to fill critical general surgery, radiology, and anesthesiology vacancies (Mueller, 2002).
Despite their importance in certain underserved rural areas, IMGs may not be a reliable source in the future because of tightened security following the September 11 terrorist attacks (Mueller, 2002). It would be difficult to replace all waiver physicians with domestic medical school graduates. To replace the 727 new J-1 waiver physicians who entered the workforce in 2000, rural areas would need to recruit one-sixth of all domestic medical school graduates with primary care training, over and above the 365 NHSC physicians and all others already practicing in the area of primary care.
To enhance retention, many steps have been taken to address key concerns of rural clinicians. There have been few evaluations of such programs, however, so little is known about the impact of different approaches.
Even when salaries are roughly comparable between rural and urban areas, as is the case for generalist and specialist physicians, rural providers tend to work more hours per week, see larger numbers of patients, and have greater demands for on-call coverage (Hart et al., 2002; Williams et al., 2001). To compensate rural providers more equitably and improve recruitment and retention, the federal and some state governments provide higher payments to physicians in some rural areas. The Medicare program offers a 10 percent supplemental payment to physicians practicing in rural areas designated as health professions shortage areas, an incentive made automatic under the Medicare Modernization Act of 2003. In addition, the act includes a new 5 percent bonus payment to physicians in designated scarcity areas (in terms of either primary care or the availability of specialists) effective from 2005 through 2007 (Hart et al., 2002; MedPAC, 2004). In a similar vein, the Utah Medicaid program has improved recruitment and retention of dentists through a 20 percent reimbursement incentive (Gordon, 2004).
Incentives for building a rural practice are also a part of federal programs for community health centers and rural health clinics. Providers may qualify for supplemental grants or higher reimbursement rates through the Centers for Medicare and Medicaid Services. For example, community health centers receive federal grants covering the cost of primary care and support services (e.g., transportation, translation) for low-income people living in medically underserved areas (Bloom et al., 2001). Rural health clinics do not qualify for grants, but can receive cost-based reimbursement for care provided by a number of midlevel clinicians.
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). Under the auspices of The Robert Wood Johnson Foundation’s Practice Sites Program during the mid-1990s, for example, state health departments in Nebraska and New Mexico created innovative locum tenums networks (RWJF, 2000a,b). These respite programs also provide an opportunity for health professionals to partake periodically of cer-
From 1977 until 2000, Mansfield University, a public institution in rural north-central Pennsylvania, offered a master’s degree in community psychology (Murray and Keller, 1998). This program recruited many of its students from rural areas; exposed students to rural issues through course curricula; trained them at rural sites under the supervision of faculty extensively involved in local concerns; and placed them in rural jobs, many in public agencies in Pennsylvania and neighboring New York. Closure of the program reflected a number of considerations: difficulty in recruiting qualified students, insufficient funding support and pressure from the state higher educational system to cut smaller programs, and lack of authorization from the state to offer doctoral training at a time when Pennsylvania was joining many other states in requiring doctoral-level training for clinical psychologists.
tain cultural and social aspects of urban environments, and this may be particularly important for those who are not from rural environments.
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). Given that rural areas are far more dependent than urban on midlevel clinicians, licensure and scope-of-practice laws can have a sizable impact on the rural workforce.
Some states allow for a broader scope of practice for midlevel clinicians and for long-distance (rather than on-site) supervision by physicians and other specialists (Hartley et al., 2002). In the case of mental health, for example, most rural states have granted prescribing authority to advanced practice psychiatric nurses (Gamm and Hutchison, 2004). A few pilot studies have found positive outcomes of expanded scope of practice for dental hygienists, although most states do not permit them independent practice (Nolan et al., 2003). There have also been recent examples of professional groups and states tightening licensure requirements or narrowing the scope of practice for some types of midlevel clinicians, such as master’s-level psychologists (see Box 4-2). Moreover, as discussed in Chapter 5, payment policies can hamper recruitment of providers if they fail to recognize the mix and complement of providers available to deliver services in rural areas.
It is beyond the scope of this report to speak to the minimum educational requirements for licensure or the appropriate scopes of practice for various types of health care professionals, but it is important to note that the decisions of professional organizations and state governments on these matters have an important impact on the rural workforce. The committee does emphasize that decisions regarding licensure and scope of practice will best serve the needs of the population if they are grounded in strong evidence on the quality of care provided by various types of health care professionals. The current evidence base is very lean, and research in this area would thus be a highly worthwhile investment.
Continuing education, whether delivered on site or remotely, provides opportunities for enhanced training, reduces professional isolation, and increases collaboration within and across the health professions. 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).
Lastly, recruitment and retention of health care professionals will likely improve to the extent that rural hospitals and other provider organizations exhibit the key characteristics associated with enhanced staff satisfaction and professional development. For example, key characteristics of “magnet hospitals,” hospitals that have exhibited success in recruitment and retention of nurses, include participatory management style, able and qualified leaders at each level of the organization (both nursing and nonnursing leaders), and executive-level nursing leadership with decentralized department structures (McClure and Hinshaw, 2002).
OPTIONS FOR MOBILIZING COMMUNITY RESOURCES
As discussed in Chapter 2, maximizing both individual and population health requires the active engagement of the entire population. Health care professionals have an important role to play, but so do the residents of a community. There is also a need for strong leadership and collaboration to muster communitywide resources in support of efforts to improve health and health care.
Evidence suggests that major improvements in the health status of the population will most likely be achieved by a shift in emphasis from treatment to prevention of disease. Behavior and environment are responsible
for more than 70 percent of avoidable mortality (McGinnis and Foege, 1993). Health care is important, but it is just one of several determinants of health (McGinnis et al., 2002).
The residents of a community make both individual and collective decisions that influence the incidence and prevalence of disease. Individual behaviors (e.g., diet, exercise, tobacco and alcohol consumption) have been linked to the emergence and progression of most if not all leading health conditions, including heart disease, diabetes, asthma, and cancer. Health is also shaped by laws and policies, employment and income, and social norms and other factors that influence individual behaviors and environmental conditions that undermine health (McGinnis et al., 2002).
Residents play an important role as well in the ongoing management of chronic conditions. Chronic conditions are long-term, frequently require ongoing care, and often limit what the individual can do. People with such conditions often see many clinicians in different care settings and must possess certain skills to navigate the health system successfully. Advice from health care providers can be conflicting, and drug–drug interactions are common (Classen, 1999). Self-care is critical to the management of many chronic conditions, as well as care provided by family and friends on which many people with chronic conditions rely (Van Korff et al., 1997).
Health literacy influences the likelihood that an individual will pursue a healthy lifestyle, interact effectively with the health care system, and engage actively in the ongoing management of chronic conditions. 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); and to navigate the health care system effectively (IOM, 2004b). Health literacy is influenced by three factors (IOM, 2004b):
Education system—Nearly one-half of all adults (or 90 million individuals) in the United States have limited functional literacy skills, where literacy is defined as a basic set of reading, writing, mathematics, speech, and speech comprehension skills (Kirsch, 2001).
Health system—A large body of evidence (more than 300 publications) indicates that most health-related materials far exceed the average reading ability of U.S. adults.
Culture and society—The shared ideas, meanings, and values of the
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.
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-
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-
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
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-
related activities. The Department of Education and state education agencies should work in partnership with local nonprofit literacy associations and libraries to measure and improve the health literacy of rural community residents by, among other things, providing access to Internet-based health resources and training in information technology.
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