RURAL NURSE PRACTITIONERS: RHAC SURVEY RESULTS. Presentation to Rural Health Advisory Committee & Flex Committee May 19, 2015

Transcription

1 RURAL NURSE PRACTITIONERS: RHAC SURVEY RESULTS Presentation to Rural Health Advisory Committee & Flex Committee May 19, 2015

2 Review: Minnesota regions

3 Review: NPs vs population, by Minnesota region 2015 licensed NPs (n=3,867) 2013 population estimate (n=5,420,380) 54% 46% 14% 17% 14% 11% 7% 4% 2% 7% 6% 3% 2% 5% 3% 6% Central West Central rthland rthwest Southern Southwest Twin Cities Out of state business address Source: Minnesota Board of Nursing licensing data (May 2015) and U.S. Census Bureau, Decennial Census (2013).

4 Review: Rural-urban commuting areas (RUCAs)

5 Review: NPs vs population, by rural-urban distribution Source: Minnesota Board of Nursing licensing data and U.S. census data, 2010.

6 RHAC NP survey In Sept 2014, surveys sent to 402 rural facilities 79 Critical Access Hospitals (60% response rate) 87 federally designated Rural Health Clinics (40% response rate) 236 other rural clinics (21% response rate) Of the clinics responding: 10% were in large rural areas 34% in small rural areas 46% in isolated rural areas CAHs are also distributed among all three rural types, and most of these are also in small and isolated (vs. large) rural areas.

7 Survey: How many NPs on staff? CAHs 80% employ at least 1 NP. Clinics 84% employ least 1 NP. Of these: 47% employ 3 or fewer NPs. 33% employ 4 or more NPs. Of these: 80% employ 3 or fewer NPs. 16% employ 4 or more NPs. Clinics in small and isolated rural areas are more likely than those in large rural areas to employ only 1 or 2 NPs.

8 Survey: What % of your primary care workforce is NP/PA/MD? Average % of each provider type, CAH v clinic CAHs (n=42) NP 27% PA 18% MD 54% Clinics (n=79) NP 29% NP 16% MD 55%

9 Survey: In which departments do NPs work? Number of facilities using NPs in these departments Family medicine Emergency medicine Geriatrics OB/GYN Urgent care Mental health Diabetes Clinics (n=71) Pediatrics 30 Family planning Internal medicine CAHs (n=47) Pain medicine 21 Other specialties* 12 Med/surg 14 LTC/nursing home Intensive care 2 3 *Other specialties include: Oncology, orthopedics and nephrology.

10 Survey: In which clinic departments do NPs work? Family med Geriatrics Urgent care Diabetes Peds/Adol Family planning Internal med Pain med Large rural Mental health Small rural OB/GYN Isolated rural Emergency medicine 11 7 Other specialties 3 4 3

11 Survey: Certified as a Health Care Home? Clinics vs. CAHs

12 Survey: In process of HCH certification? Clinics vs. CAHs

13 Survey: Certified as a Health Care Home?

14 Survey: Do you use NP-led teams for care coordination? Clinics vs. CAHs 77% 79% Yes 23% Clinics (n=64) Yes 21% Hospitals (n=19)

15 Survey: Do you use NP-led teams for care coordination? Clinics only, by rurality 100% 70% 76% Yes 30% Yes 24% Large rural (n=9) Small rural (n=23) Isolated rural (n=29)

16 Survey: Do NPs have admitting privileges in your hospital?

17 Survey: Challenges to recruiting NPs? Clinics vs. CAHs 67% 70% Yes 33% Yes 30% Clinics (n=82) Hospitals (n=44)

18 Survey: Challenges to recruiting NPs? Clinics only, by rurality 79% 68% 61% Yes 21% Yes 32% Yes 39% Clinics in large rural (n=14) Clinics in small rural (n=28) Clinics in isolated rural (n=36)

19 Survey: Challenges to recruitment Most common by far: Rural location Lack of amenities, lack of work for spouse, lack of housing. Distance, esp. for remote sites requiring staff to be away from home for 1-2 days when on call. Tough for new grads especially. ER call and other hospital care hours as part of job. Lack of rural experience: Candidates often right out of school, so training takes a long time. Level of independence required; limited MD oversight. Tight job market lots of offers/opportunities for NPs. Salary issues, including expectations w/doctoral degree. physician on staff willing to supervise. Transitioning to a Advance Practice ER model with robust e-tele support.

20 Survey: Incentives used in recruitment 70% of clinics and 64% of hospitals report using some kind of incentive in recruiting NPs. Incentives used: Sign-on bonus: 28% of clinics, 47% of CAHs Loan forgiveness: 38% of clinics, 43% of CAHs Cover cost of collaborative management agreement: 30% of clinics, 9% of CAHs Other (each used by fewer than 5% of facilities) Moving expenses Certification bonus Internships/practicum experiences Flexible hours

21 Survey: Challenges to retaining NPs? Clinics vs. CAHs 79% 76% Yes 21% Clinics (n=77) Yes 24% Hospitals (n=42)

22 Survey: Challenges to retaining NPs? Clinics only, by rurality 100% 81% 70% Yes 19% Yes 30% Large rural (n=14) Small rural (n=28) Isolated rural (n=36)

23 Survey: Incentives used for retention 80% of clinics and 62% of hospitals report using some kind of incentive to retain NPs. Incentives used: Continuing education budget: 75% of clinics, 53% of CAHs Advanced training opptys: 34% of clinics, 26% of CAHs Tuition assistance: 21% of clinics, 26% of CAHs Cash bonuses: 17% of clinics, 19% of CAHs Cover cost of collaborative mgmt agmt: 34% of clinics, 15% of CAHs Mentor program: 16% of clinic, 9% of CAHs Other (each used by less than 5% of facilities) Flexible scheduling As an FQHC with flat rate, can focus on patient care, not volume Exploring cash/quality bonuses

24 Survey: Recruitment and retention recommendations Policy-level Address challenge of CMS rules for emergency rooms and other services require supervision levels by physicians not consistent with MN's Nurse Practice Act. Practice-level Team approaches Monthly Medical Staff meetings. Involvement of NPs in performance and process improvement: e.g., Monthly Drug Formulary review with team; and Post-Trauma Huddle. Good collaborating physicians. MD attitudes toward the FNP needs to be one of collaboration and respect. Examples of MDs not agreeing NPs should admit pts even when they have admitting privileges, or a bias toward hiring MDs vs. NPs. Compensation: Increase pay, esp. starting wages; reimburse mileage. Increase office visit times. Increase administrative time to get charting done. When covering call and clinic, establish guidelines where clinic visits are walk-in only.

25 Survey: Recruitment and retention recommendations, cont. Educational programs Expand enrollment in NP programs. Encourage NP programs at community colleges and/or remote (online). Create rural health care track or courses. Create an NP-to-MD track. Require that part of NP education be in a CAH and in a shortage area. Require a residency - NP training is limited to observation and is limited in scope. Expand number of training sites. Expand loan forgiveness programs. Create Additional incentives for individuals to go back to school to obtain NP or PA licenses, with incentives for practicing in rural areas. In-house educational/training support Grow your own : Set up an RN-to-NP loan payback program with paid time off for education. Mentoring new hires has been very successful. Provide CALS or ATLS training - gives greater sense of security in ER. Provide training early on in the Electronic Health Record system.

26 Survey: Would your CAH be interested in a distance education/hybrid model NP residency program? 58% Yes 42% n=43 Critical Access Hospitals

27 Survey: Suggestions for such an NP residency program? Inpatient/acute care training. Trauma training such as CALS this would ramp up observation of rural ER care. OB and/or surgery as part of the rural rotation. Admission/discharge abilities. Mentorship. Online training. Assistance with tuition/loan payback. Allow CAHs to sponsor an NP for an ER residency in a tertiary facility in exchange for years of service postresidency.

28 Discussion Reactions? Next steps?