Background Information on Minnesota s Health Care Workforce

Background Information on Minnesota s Health Care Workforce The Workforce Work Group has assembled background information on Minnesota s health care workforce for your review prior to the presentation of the Work Group s recommendations on May 3 rd, 2012. Parts of this document include presentations. This is not meant to be a formal briefing paper on the health care workforce but a compilation of workforce resources including presentations made by state experts to the Work Group, fact sheets, and published reports to better understand Minnesota s workforce trends and issues. Order of Exhibits: Workforce Demand and Supply Workforce Sector specific Trends/Issues Mental Health Substance Abuse (presentation to Work Group by Nancy Dillon/DHS) Excerpts from Minnesota Department of Human Service s Status of Long term Care in MN Report Excerpts from Minnesota Department of Health s (MDH) Telehealth report Minnesota s Primary Care Shortage Report Higher Education (presentation to Work Group by Diane O Connor/OHE) Medical Education and Research Costs (MERC) MN Health Professional Loan Forgiveness Programs Health Care Provider specific Data APRNs (presentation to Work Group by Shirley Brekken/MN Board of Nursing) MDH Fact Sheet: RNs MDH Fact Sheet: Dentists MDH Fact Sheet: Dental Assistants MDH Fact Sheet: Dental Hygienists MDH Report on Physicians Health Care Workforce Occupation Data (MDH/US Bureau of Labor Statistics) Page 1 of 81

Workforce Demand and Supply Workforce Work Group Goal: to ensure that MN has the health workforce necessary to deliver responsive, high quality care to its residents Workforce Demand and Supply Equation (simplified) Demand for X health care professionals (MDs, RNs, lab techs, etc.) to meet need Demand factors include: demographics such as age; population growth; gender; population health status needs; changes in health coverage; need for culturally competent care Supply of Y health care professionals Supply factors include: workforce demographics such as age, gender; new graduates through education and training; relocation/in migration Care delivery system characteristics Provider mix; roles and scope; productivity expectations; new services; replacement of inpatient with outpatient; health care home/acos; technological advancements in care delivery modalities; emphasis on interprofessional collaborative practice Leaving a gap of Z workers Strategies to fill the gap include: state and federal investments and incentives in health care training and education; regulatory changes to expand reach and scope of trained professionals; role of technology; care delivery system redesign The Workforce Development Pipeline Prepare K-12 students in basic science; expose to health careers & role models Recruit traditional & non-traditional students Incent education & training programs in high need settings; encourage interprofessional practice Encourage grads to seek employment in high need settings Retain the health care workforce Redesign health care delivery; realign reimbursement with quality Page 2 of 81

4/27/2012 Governors Health Reform Task Force Workforce Work Group Mental Health and Substance Abuse (MHSA) Workforce Needs Nancy Dillon Ph.D, RN, CNS-BC Minnesota Department of Human Services Increased Demand for MHSA: Possible Factors* Increase in number of patients utilizing services Growing and aging population Mental health parity, Affordable health care act Some progress in anti-stigma efforts Psychiatric problems related to: Economic downturn Psychological toll of two wars Direct marketing to the public for psychoactive meds Ask your doctor if the addition of Abilify to your antidepressant is right for you? Categories of MHSA Workforce Advanced Practice Registered Nurses (APRN)* Behavior Analysts Certified Peer Specialists Licensed Alcohol and Drug Counselors (LADC)* Licensed Professional Counselors (LPC) Marriage and Family Therapist (LMFT)* MHSA Categories (con t) Occupational Therapists (OTs) Psychiatrists* Psychologists* Registered Nurses Social Workers (esp. LICSWs)* * Connotes HRSA definition as Mental Health Professional Page 3 of 81 1

4/27/2012 Current Supply and Demand for Psychiatrists Estimated need of 25.9 psychiatrists/100,000 population With current population of 300,000,000, this is 78,000. Current supply is ~ 48,000 total or (~ 16/100,000) Current gap = at least 30,000 Much greater supply vs. need gap for child and adolescent psychiatry (~ 7,500 total) Sources: Konrad et al, Psych Services, 60: 1307-14, 2009 Psych Times Series The Bureau of Health Professions predicts demand for general psychiatry services will increase nearly 20% between 1995 and 2020 100% increase in the need for child and adolescent services Board Certified Psychiatrists Minnesota 2010 Region by mailing address 2010 Certified in Psychiatry EXCEPT Child Certified in Psychiatry and Child Psychiatry Certified in Child Psychiatry only Total Advanced Practice Registered Nurses Minnesota Central 26 3 0 29 Certified Nurse Practitioners 2792 Acute Care 55 Northeast 18 0 0 18 Adult 489 Adult Acute Care 2 Adult Psychiatric/Mental Health 56 Northwest 14 1 3 18 Family 1224 Family Psychiatric/Mental Health 28 Gerontological 286 7 county Metro 287 41 4 332 Neonatal 156 Pediatric 401 Pediatric Acute Care 28 Women's Health Care 256 Southeast 73 17 0 90 Southwest 15 3 0 18 Total 443 65 7 505 Page 4 of 81 2

4/27/2012 Advanced Practice Registered Nurses Minnesota Certified Clinical Nurse Specialists 514 Adult Health 220 Adult Psychiatric/Mental Health 201 Advanced Diabetes Management 8 Child Psychiatric/Mental Health 35 Community Health 7 Critical Care - Adult 19 Critical Care - Child 1 Gerontological 22 Home Health 0 Neonatal 5 Pediatric 17 Advanced Practice Registered Nurses National Issues Entry into Advanced Practice will by DNP as of 2015 As of 2014 Certifying body will only offer Family Psych NP for new applicants Others will keep their certification and continue to function. Due to lack of applicants for the other certifications Data from Other Disciplines The plan is to gather similar data in the next 2 years. Addiction Treatment Workforce Facts Workforce estimated at 200,000 Average counselor is 45 y.o. female seeing about 29 clients in a 50 hr workweek 50% are female, but 68% of clients are male Workforce contines to gray ((between 40 55 y.o.) 85% or RX professionals are white but 44% of clients are non-while Page 5 of 81 3

4/27/2012 FACTS (con t) Average LADC counselor salary is @ $34,000 58% of all professional perceive substance abuse counselors as having a lower status than other helping professions Nearly ½ report spending 21-605 of time on paperwork Majority spend less than 50% of time on counseling Substance Abuse Workforce difficulties Priority of family and community, Individual concerns are considered a lesser priority (career development STIGMA Some who pursue work/credentials in substance abuse are actually shunned by their communities ADAD Recommendations Examine workforce development projects Target unemployed when traing dollars are available Present ATTC DVD Imagine Who You Could Save at multiple venues with panels Collaborate with training programs on standardized curriculum Bring together training programs with field to discuss training gaps Recommendations (con t) Create Learning Days 90 minute webinar recorded and downloaded on ADAD website Free to all providers with 1.5 credit ours of CEU Provided by experts Page 6 of 81 4

4/27/2012 Resources 1. www.addictioncareers.org 2. www.bbht.state.mn.us 3. www.attcnetwork.org/explore/priorityar eas/wfd/overview/whatiswfd.asp 4. www.attcnetwork.org/explore/priorityar eas/wfd/overview/surveys.asp 5. www.marrch.org/displaycommon.cfj?an= 1&subarticlenbr=141 Child and Adolescent Issues Those professionals with licenses are needed statewide but especially in Greater MN SW, Psychology, Marriage and Family Therapy, Nursing, Behavioral Health and Therapy, Psychiatry Require experience specific to treating and working with children with MH diagnoses Diversity of providers is also a need Have to increase #s and to retain those workers we have Adult Mental Health Issues Anticipated Supply and Demand of Psychiatrists? Limited pool Fewer professionals seeking these specialties Faculty limited STIGMA Salaries Anticipated Demand? Anticipated Supply? Time Page 7 of 81 5

4/27/2012 CURRENT SHORTAGE Best data: Study by University of North Carolina commissioned by Health Resources and Services Administration (HRSA) Demonstrated shortages for all MH professionals, especially prescribers 77% of U.S. Counties have a severe shortage of prescribers, with over half their need unmet 96% of US counties have some unmet need Konrad et al, Psych Services, 60: 1307-14, 2009 Potential Options and Concerns 1. Primary Care Physicians take on more psychiatric patients already overloaded and not doing the best job in treating people with psychiatric problems need consultation/training and support 2. Train more Psychiatrist $100,000 per residency slot (times 45,000 = $4.5B) 3. Train more APRNs and Physician Assistants in Psychiatry very little training in psychology or psychotherapy Potential Options and Concerns 4. Psychologists Prescribing Authority guild war. What is adequate training in basic science medicine and clinical science medicine to prescribe? Conclusions Current national shortage of MH professionals at all levels, especially prescribers All projections estimate the gap between unmet need and supply will widen substantially over the next 20 years Traditional workforce strategies alone will do little to mitigate this projected gap Training, recruitment and retention strategies must be directed at maintaining current supply and learning how to use that supply most effectively Page 8 of 81 6

4/27/2012 Conclusions (continued) Need to do business differently Integration and collaboration models will likely be a significant strategies of the solution Telehealth will play a role Training strategies should be directed at selecting and preparing trainees who are most likely to succeed in this rapidly changing, multiple priorities environment Recruitment and retention must be focused on the new world of health care reform Collaboration Models Clearly must change the way we do business Primary Care Physicians with Consulting Psychiatrist Advanced Practice Nurse Practitioners as LIPs with Collaborating Psychiatrists (practice agreements or prescriptive agreements) Psychologists with Supervising Psychiatrists Physician Assistants as psychiatrists extenders Over-Arching Concerns Small pool to draw from Sites for clinical experiences/coaching in preparation for licensure Loan repayment - graduate education required Lower paying than many other specialties Tuition reimbursement to retain current Stigma of working with these populations Lack of diversity in providers A major issue in all areas Thanks to: Martha Aby, Children s Mental Health Division Karen Christensen, Alcohol and Drug Addiction Division (ADAD) Cindy Swan-Henderlite, ADAD Michael Landgren, AMH Dr. Alan Radke, Chief Medical Director, DHS Page 9 of 81 7

Status of Long-Term Care in Minnesota 2010 A Report to the Minnesota Legislature Continuing Care Administration PO Box 64974 St. Paul, MN 55164-0974 651-431-2600 Page 10 of 81

Status of Long-Term Care in Minnesota 2010 I. Purpose of This Report This document summarizes the status of long-term care 1 for older persons in Minnesota through calendar year 2009, and was developed in response to a legislative mandate (M.S. 144A.351) to biennially update the legislature on the effects of legislative initiatives to rebalance the state s long-term care system. This report describes the changes in the state s system that have resulted from a comprehensive set of historic long-term care reform provisions prepared by the state s long-term care task force and enacted by the Minnesota Legislature in 2001. Since that time additional provisions to reduce reliance on the institutional model and to expand the availability of home and community-based options for older persons have been enacted. Demographic and market changes, as well as significant shifts in the state and national economic climate, have further affected Minnesota s long-term care system. This report provides an update on the current status of the state s long-term care system for older Minnesotans. As required by statute, this report includes demographic trends; estimates of the need for longterm care among older persons in the state; and the status of home and community-based services, senior housing and nursing homes serving older persons. Also discussed are the activities and roles of the Minnesota Department of Health in regulation and quality assurance, significant changes made during the 2009 Legislative session, some of the initial impacts of state and national health care reform, and other issues that will affect long-term care in the future. The report concludes with four long-term care benchmarks that measure the progress made on key elements of long-term care reform in Minnesota and a brief summary of recent policy shifts and resource challenges. The Minnesota Department of Health contributed data and other information necessary for the completion of this report. Counties and Area Agencies on Aging/Eldercare Development Partnerships also contributed data and comments on the changes that have occurred in the availability of services over the past two years. The cost to prepare this report was approximately $15,000. 1 Long-term care and long-term support these phrases are used interchangeably and defined as a variety of services and supports to meet health or personal care needs over an extended period of time intended to help a person maximize independence and functioning. U.S. Department of Health and Human Services, National Clearinghouse for Long-Term Care Information Understanding LTC Web site at http://www.longtermcare.gov, last updated October 22, 2008 1 Page 11 of 81

Status of Long-Term Care in Minnesota 2010 II. Demographic Trends and Need for Long-Term Care Earlier reports to the Legislature on Minnesota s system for providing long-term care for older Minnesotans (2001, 2004, 2006 and 2008) have charted the demographic trends that are expected to have a profound impact on the need and demand for long-term care in Minnesota. This section summarizes those trends and reflects Minnesota s experience over the past two years in interpreting the impact of these forecasts. A. Demographic Changes The demographic trends section of this report has altered very little since the original 2001 report: Minnesota still ranks just about in the middle of states in its proportion of elderly. The U.S. average is 12.6 % persons age 65 and older, Minnesota is at 12.2. Across the U.S., inmigration of retirees to warmer climates, and out-migration from the northernmost tier of states has resulted in relatively slow growth of Minnesota s older population over the past 3 decades. The current slow growth in numbers of elderly is also partly attributable to the lower birth rates during the Great Depression, when today s oldest persons were born. However, beginning in 2011 the first wave of boomers, born between 1946 and 1964, begins to turn 65. For the next 30 years the boomer cohort will dominate Minnesota s population growth. Between 2010 and 2020, the population 65+ will increase by 40 %, while the under-65 population is forecast to increase by about 4 %. Between 2020 and 2030, the comparable figures are 36 % in the older group and less than one percent for the younger group. Minnesota now ranks second among the states in terms of life expectancy at birth: 78.82 years (behind Hawaii at 80.0) 2. Longer life expectancy in Minnesota, coupled with a small net inmigration of persons age 85+ returning to Minnesota after living their younger retirement years in another state, contribute to gradually increasing numbers and proportion of the oldest old. Between 2030 and 2050, the number of persons aged 85 and older is projected to double to 250,000 persons. Num ber of Minnesotans Aged 85+ by Decade 2000-2050 300,000 250,000 200,000 150,000 100,000 50,000 By 2060 the overall numbers of older persons are projected to decline slightly because nearly all the baby boom generation will have died and the next generation will not be as large. Nonetheless, an older society will be a permanent fixture of the state s demographic profile into the foreseeable future. 0 2000 2010 2020 2030 2040 2050 Source: Office of MN State Demographer 2 Harvard University Initiative for Global Health and the Harvard School of Public Health, Business Week, September 15, 2006. 2 Page 12 of 81

Status of Long-Term Care in Minnesota 2010 B. Need for Long-Term Care The need for long-term care in Minnesota is tied to both the demographic projections and disability rates. Today s elderly are, in general, healthier than their age peers just a generation ago. Age-specific disability rates in the United States have been decreasing at about 3 % per decade for the past several decades 3, partly due to improved public health and nutrition during this cohort s childhood (1920s and 30s), and partly due to advances in medical care, e.g., hip or knee replacements, and prescription drugs that reduce pain and allow more people to function independently. However, as noted above, the number of very old (and most likely at risk) is projected to continue to increase slowly through 2020, and then quite rapidly for the next two decades. Since the 1950s disability rates by age have generally declined. Nonetheless, persons aged 85 and older have significantly higher prevalence of chronic illness and rates of disability, 4 and although Minnesota s disability rates are below the national average 5 the overall need for long-term care will increase because functional disability increases with advancing age despite the previously mentioned slowdown in the rate at which this occurs. 6 Over two-thirds of persons age 85 and older have at least one disability, and older persons are more likely to have multiple disabilities, that is to say several chronic conditions, each of which poses a challenge to the individual s ability to function independently. Percent of Persons with a Disability by Age Group, United States 85 and older 75 to 84 65 to 74 25 42 68 Whether the gradual reduction in disability rates among elderly will continue into the future is unknown. For example, reduced rates of cigarette smoking may positively affect future health status, but the rising rates of obesity and adult-onset diabetes could easily offset this positive trend. 45 to 64 15 18 to 44 5 Source: CDC, 2007 C. Implications for LTC Labor Force In the most recent surveys in Minnesota, over 90% of long-term care is provided by children, spouses and other non-paid relatives and friends 7. The next generations of older Minnesotans have significantly fewer children than previous cohorts 1.9 children per couple today compared to 3.2 children per couple in the 1950s. In addition, the proportion of older persons who are expected to be living alone (whether due to death of a spouse, divorce, or never having 3 National Long-Term Care Survey, 2006. 4 He et al (2005) 65+ in the United States: Current Population Reports, National Institute on Aging. 5 2009, Thomson Reuters, Minnesota State Profile Tool: An Assessment of Minnesota s Long-Term Support System, Table 1.2 (p. 8). 6 Houser, Ari (2007) Long Term Care Research Report, AARP Public Policy Institute. 7 Minnesota Board on Aging, 2005 Survey of Older Minnesotans. 3 Page 13 of 81

Status of Long-Term Care in Minnesota 2010 been married) is also projected to increase significantly for the boomer generation 8. These trends toward smaller families and smaller households will inevitably result in less family and unpaid support, and unknown increase in demand for paid help. Simultaneously, the state demographer forecasts a significant reduction in the state s labor force growth: an older workforce (with expectations for employee-sponsored health care), and increasing competition for scarce younger employees. The long-term care industry depends on low-wage workers, and because of high turnover in many long-term care positions, the industry is also dependent on new workers coming on line. Net Labor Force Growth in MN by Decade 1 600000 450000 300000 150000 0 1970-80 1980-90 1990-00 2000-10 2010-20 2020-30 Source: Office of MN State Demographer Notwithstanding the likelihood of some inmigration from other states and other countries, the number of new workers in Minnesota in the decade from 2010 to 2020 is forecast to be about a third of that seen in the current decade. In a word, the projected labor force supply for long-term care is likely to be inadequate without significant changes in labor deployment, recruiting and maintenance. As the chart above shows, the labor force growth in Minnesota will decrease by two-thirds in the upcoming decade. Competition for new workers will put new demands on Minnesota s longterm care industry already coping with low wages. In light of the continued trends, including the growth in demand for long-term care services and the aging of the general and workforce populations, the expansion and development of the direct care workforce is at risk of not keeping pace with the need for additional staff in the field of long-term care, including home and community-based services. According to the federal Bureau of Labor Statistics (BLS), more than 1 million new and replacement nurses will be needed nationally by 2018. In addition, according to a 2007 study conducted by the PriceWaterhouseCooper Health Research Institute, the turnover rate of new nurses entering the profession is 27.1 %. The long-term care industry, which is heavily financed through public monies provided by the Medicaid and Medicare programs, also employs very large numbers of direct care paraprofessional or allied health staff. These positions typically require less formal education and are characterized by lower wage and benefit structures and low retention rates. 8 The proportion of boomers who are projected to live alone is nearly twice the rate of current elderly (86.7 % higher). Census Bureau: Projections of the Number of Households and Families in the United States 1995-2010. 4 Page 14 of 81

Status of Long-Term Care in Minnesota 2010 Occupation Home Health Aides Nurse Aides & Orderly/Attendant Bureau of Labor Statistics (BLS) U.S. Labor Data Projections 2008-2018* Actual Projected % Employment Employment 2018 Change 2008 922 1,383 +50.0% 3 2,454 3,194 +30.2 2 RN 2,619 3,200 +22.2 1 LPN/LVN 754 909 +20.6 4 *thousands of jobs Rank (by Number of New Jobs Projected) Workforce growth and demand, as well as turnover, for paraprofessional staff positions such as Certified Nursing Assistants or Aides (CNAs), Home Health Aides (HHAs), Personal Care Attendants (PCAs), and associated fields remains very high despite the recent economic downturn. According to BLS projections, growth in nursing as well as the paraprofessional fields will remain high for the foreseeable future. In addition, passage of recent federal health care reform is anticipated to improve access to health coverage, likely increasing the demand for health care workers - especially direct care workers, who provide the majority of care for those with chronic care needs. Part of the problem of meeting the increased demand for a larger long-term care workforce is that needs change more rapidly than training can be provided. Some of this increase in demand may be alleviated by initiatives such as telemedicine and healthcare information technology (HIT), both of which have the potential to reduce some of the demand for direct care staff. However, the availability of an educated direct care workforce remains a key component of quality care at all levels of the long-term care spectrum. The Department of Human Services administers several programs which are designed to help address the recruitment, retention, development and training needs of the direct care workforce. The first, the Nursing Facility Employee Scholarship Program, was implemented in 2001. This program provides funding to participating nursing facilities in the form of a cost-based rate, for use as scholarship funding for eligible employees - those who work an average of 20 hours or more per week (excluding Registered Nurses (RNs) and most management staff). These scholarship funds are specifically dedicated for education in the field of long-term care or training leading to career advancement within their employing facility. 5 Page 15 of 81

Rural Health Advisory Committee s Report on Telemental Health in Rural Minnesota July 2010 Office of Rural Health & Primary Care P.O. Box 64882 St. Paul, MN 55164-0882 www.health.state.mn.us/divs/orhpc Phone: 651-201-3838 Toll free: 800-366-5424 Fax: 651-201-3830 Page 16 of 81

Summary and Recommendations Residents of many areas in rural Minnesota lack timely, affordable, accessible, quality mental health services. To obtain screening, diagnosis and treatment, rural residents must often wait weeks and even months for an appointment with a mental health professional and travel great distances to receive services. Many rural residents opt to seek care through their local primary care providers. Primary care providers may not have adequate training or support for diagnosing and treating mental health disorders. Inconsistencies in insurance coverage and third-party reimbursement for mental health services in primary care settings create additional obstacles to the provision of mental health services. 69 Many barriers to the availability of mental health services in rural Minnesota can be addressed through the practice of telemental health, which is the provision of mental health services using a live exchange between remote sites through videoconference connections. Through this technology, consultation and care is available in a growing number of rural community health centers, primary care clinics, hospitals and emergency departments. As access to and understanding of the technology and equipment increases, telemental health services will commonly be offered in more settings such as nursing homes, schools and individual households. Videoconferencing also allows for ongoing education and training of rural mental health and primary care providers. The Rural Telemental Health Work Group recommends that telemental health services be enhanced and expanded in rural Minnesota. The key findings address the benefits of and barriers to increased telemental health services. Key Findings Benefits. Several benefits from telemental health in rural Minnesota were identified, including: Increased access to mental health services. All mental health procedures that are delivered in person can be delivered remotely via telemental health. 70 This provides a means for combating workforce geographic limitations. Increased diagnosis and treatment yield better outcomes. Earlier intervention and easier access helps patients engage in their care and, ultimately, this will improve mental health outcomes and save health care costs. Cost-effective delivery of mental health services. More than 85 percent of patients seen via telemedicine remain in their local communities, resulting in lower costs of care and further enhancing the financial viability of the community 69 Bachman, J. et al (2006) Funding Mechanisms for Depression Care Management: Opportunities and Challenges. General Hospital Psychiatry 28 (278-288). 70 Novins DK, Weaver J, Shore J. (2008) Telemental Health Talking Points. Telemental Health Guide, www.tmhguide.org Page 17 of 81

hospital or clinic. 71 Other potential cost savings come from reduced wait times and a reduction of no-show rates. Costs are reduced overall for patients, providers and health systems, even after including start-up costs for the necessary equipment and technology infrastructure. Enhanced coordination of care. As the integration of primary care and mental health continues, more psychiatrists are providing peer consultation to family practice physicians, especially in rural Minnesota. Research shows that patients most often discuss their mental health concerns first with their primary care physician. Telemental health also creates an opportunity to engage additional mental health providers. Barriers. The Rural Telemental Health Work Group identified barriers to improving or increasing telemental health services in rural Minnesota. Additional barriers exist; however, many relate to telehealth overall. The following are barriers to telemental health specifically: Information and Training. Minnesota lacks a central resource for telemental health information and training. Each facility or organization embarking on the provision of telemental health services must locate its own information, causing a great duplication of effort. Reimbursement. A lack of uniform, consistent and equitable reimbursement for telemental health services creates a significant barrier to providing the service. Infrastructure and Technical Support. Telemental health cannot happen without the Internet connectivity and equipment. There is inconsistent broadband coverage throughout Minnesota. The start-up costs associated with telemental health can be cost-prohibitive, especially for small, independent facilities and providers. Mental Health Workforce Shortages. The underlying issue in telemental health is the shortage of mental health providers in rural Minnesota. The number of psychiatrists and nurse practitioners certified in adult or child psychiatry has decreased. A limited number of psychologists and licensed clinical social workers are practicing in rural areas. Much needs to be done to increase the number of mental health providers practicing in rural Minnesota. Recommendations Telemental health services have a positive impact on the provision of mental health services in rural Minnesota. The following recommendations address steps toward achieving equal access to telemental health services throughout Minnesota: A. Expand and promote a telemental health resource hub (website) to identify best practices, and to educate, inform and provide resources for health care professionals working in telemental health. Existing organizations, such as the Great Plains Telehealth Resource and Assistance Center (GPTRAC) and the 71 Woods and Poole Economics, Inc. (2006) Complete Economic and Demographic Data Source. Page 18 of 81

Center for Telehealth and E-Health Law (CTel), should enhance resource availability and coordinate sharing of information to include: Showcasing of models for integrating telemental health into existing programs (e.g., co-location of services, billing, scheduling). Specific health care situations in which telemental health offers a solution or helps achieve a goal (e.g., reduced overall emergency department admissions through increased access to telemental health services). Strategies for replication of successful telemental health programs. Information about common liability risks and misconceptions about telemental health services by primary care providers (e.g., collaborative agreements and remote assessment). Examples and potential use of videoconferencing technology for serving diverse cultures by incorporating translation and interpreter services into the telemental health service. B. Enhance the web-based Minnesota Telehealth Registry to identify telemental health providers who are available for consults with rural primary care physicians or to provide telemental health services. Target the tracking and registry of child psychiatrists, as this is an area of great need. Providers should indicate what percentage of their time or practice will be devoted to telemental health services. C. Create a statewide committee to work on resolutions to reimbursement and regulatory issues. The purpose of the committee is to work with payers on statewide payment, administrative (including credentialing) and regulatory issues and to ensure the implementation and understanding of federal regulations affecting telemental health reimbursement and administration. D. Gather existing or develop new methods to assess telemental health program quality and sustainability factors. Telemental health quality measures should be developed to determine optimal service thresholds. Efficiency and effectiveness should be included in quality measures. Consumers, providers and health plans should provide input into the design of the quality measures. Best practice models can serve as templates for sustainable telemental health services. E. Support technical and telehealth coordinator staff capacities to operate and maintain equipment used to provide telemental health services. Small, rural hospitals and clinics are especially in need of technical support and may not have staff with the expertise to run equipment and troubleshoot technical issues. Support staff by offering training, sharing issues and answers, and clarifying telemental health coordinator job duties and responsibilities. F. Inform stakeholders of existing state, federal and foundation grant funding for starting, maintaining or enhancing telemental health services. Especially needed are funding sources for basic equipment. Consider increasing the amount of funding or dedicating a portion of grant programs to the Page 19 of 81

Telemental Health in Rural Minnesota 49 advancement of telemental health in rural Minnesota. Potentially applicable grant programs include: Community Services and Community Services Development Grant (Minnesota Department of Human Services), Rural Flex Grant (Minnesota Department of Health), and the Telehealth Network Grant (Health Resources and Services Administration). Examples of funding needs include: Equipment for rural mental health crisis teams to access in-time remote psychiatric consults. Laptops for rural mobile medical units and rural home visiting nurses to enable remote access to telemental health services. Telemental health services for incarcerated individuals and consultations for jail health providers. Grant funding could offset costs of diagnostic assessment, medication management and discharge planning. Strategic planning and business planning for sustainable telemental health programs. G. Connect psychiatric and mental health training programs with rural practice sites providing telemental health services for practicums and clinical training opportunities. Build upon and support existing programs and models in the state as demonstration projects and best practices. Create incentives and assistance in developing telehealth curriculum and training. Promote best practices and opportunities for practicing telemental health to new and upcoming graduates. H. Enhance loan forgiveness programs for mental health professionals. The location of the patient should be a consideration for whether some mental health providers are eligible for participation in state and federal loan forgiveness programs, such as the National Health Service Corp (NHSC). If a mental health provider, regardless of the location, is treating a patient located in a Mental Health Professional Shortage Area, the provider should receive enhanced reimbursement or be eligible for loan forgiveness programs. Virtual presence for some mental health professions with extreme shortages, such as child psychiatry, should be considered equal to physical presence. I. Educate state policymakers on the critical need for telemental health services in rural areas. Demonstrate potential cost savings if needs are addressed and highlight proven models in other states. Page 20 of 81

Minnesota s Primary Care Provider Shortage Strategies to Grow the Primary Care Workforce Minnesota s Primary Care Workforce Planning Grant FINAL REPORT December 2011 Governor s Workforce Development Council P o l i c y S o l u t i o n s t h a t W o r k f o r M i n n e s o t a Page 21 of 81

about the primary Care workforce planning grant The Governor s Workforce Development Council (GWDC) formed the Steering Committee for the Primary Care Workforce to apply for and implement a one-year, $150,000 planning grant from the Health Resources and Services Administration. The Steering Committee was chaired by GWDC member Laura Beeth, System Director of Talent Acquisition for Fairview Health Services. The grant was implemented between September 2010 and September 2011. Steering Committee members Laura Beeth, Chair Edward Reynoso Macaran Baird Mary Rothchild Barbara Brandt Jennifer Schaubach Valerie DeFor Mark Schoenbaum David Etzwiler Richard Smestad Jane Foote Dan Smith Ann Gibson Susan Speetzen Jill Myers Table of Contents Executive Summary...page 1 Needs Assessment....page 3 Goals and Strategies.....page 11 Endnotes...page 17 Committee Staff Bryan F. Lindsley, GWDC Executive Director acknowledgements This report is the collaborative work of the GWDC s Primary Care Workforce Steering Committee. The GWDC acknowledges the following individuals, in addition to countless other stakeholders, who contributed their time and expertise to the planning process. Laura Beeth, System Director of Talent Acquisition for Fairview Health Services, chaired the Steering Committee and served as the primary representative of the GWDC. Bryan Lindsley, GWDC Executive Director, served as grant manager and lead staff to the Steering Committee. Valerie DeFor, Director of Statewide Healthcare Education Industry Partnerships for HealthForce Minnesota, helped write the grant application and served as principal author of the final report. Mark Schoenbaum, Director of Minnesota Office of Rural Health and Primary Care, guided the application to the grant and facilitated policy development. Jill Myers, Supervisor of Health Care Workforce Analysis Program at the Department of Health, helped write the grant application. HealthForce Minnesota provided project management. Rebecca Radcliffe arranged and facilitated constituent meetings and collected input. Nick Maryns, GWDC Senior Policy Analyst, designed and formatted the report. about the governor S workforce development CounCil The GWDC is at the center of a number of initiatives that are addressing the needs of Minnesota and its economy. The council develops policy recommendations, oversees Minnesota s workforce development system, and convenes workforce partners around strategic goals and initiatives to ensure that businesses have the skilled workers they need to compete in the global economy. mandate and membership As Minnesota s state Workforce Investment Board, the GWDC is mandated and funded by Section 111 of the federal Workforce Investment Act of 1998 and further defined by Minnesota Statutes, section 116L.665. Council membership is dictated by state statute to include the following sectors: business and industry, communitybased organizations, education, local government, organized labor, state agencies, and the state legislature. Page 22 of 81 v2

Executive Summary Minnesota is projected to face a shortage of primary care providers in the next ten years. In response to primary care workforce shortages across the country, and with the passage of the Affordable Care Act, the Health Resources and Services Administration (HRSA) allocated funds to support primary care workforce planning on a statewide basis. The funds were released via a competitive grants process which required states to submit an application responsive to the goals of the agency. Each state had a single eligible applicant in Minnesota, the identified applicant was the Governor s Workforce Development Council (GWDC). Minnesota s application was submitted in July 2010 and notification of funding was received on September 24, 2010. PurPose The purpose of the planning grant was to:» Identify and engage all Minnesota healthcare workforce stakeholders in a new and comprehensive workforce planning effort,» Analyze existing workforce data and develop plans and strategies to collect additional data and information, and» Develop a comprehensive plan which will, when implemented, ensure an increase of 10 25 percent in full-time primary care professionals over the next ten years. Definition Primary care providers do not operate in isolation but are instead part of a much larger team of allied health professionals, specialty practitioners, and support personnel. For purposes of this planning grant, HRSA encouraged states to use a more narrow definition of primary care and to focus on physicians (family practitioners), physician assistants, and nurse practitioners. Minnesota needs multiple strategies to increase the number of primary care providers in the state. Process Led by the Primary Care Workforce Steering Committee established by the GWDC and chaired by GWDC member Laura Beeth, the planning process began in October 2010. A regional meeting approach was determined to be the best way to gain input into the plan from across Minnesota. The regional meetings also allowed for unique regional needs and concerns to be expressed. In addition to the regional meetings, constituent meetings were held to gain input on specific disciplines. Over 750 people attended 21 regional and constituent meetings to provide input into the creation of the Primary Care Workforce Report. Formal meetings featured an overview of the current supply and demand of primary care physicians, advanced nurse practitioners, and physician assistants, as well as educational capacity and demographic highlights. Attendees ranged from consumers to CEOs, community Page 23 of 81 Governor s Workforce Development Council 1

health workers to city planning officials, physicians to pharmacists, and educators to EMTs. Attendees were asked to respond to three questions: 1. What changes/developments in primary care (positive and negative) do we know will occur for certain in the next ten years? 2. What changes/developments in primary care (positive and negative) might catch us by surprise? This report and input from regional meetings can be found at www.gwdc.org/publications 3. What ideas/strategies/programs/initiatives/training options, et cetera, will help increase the availability of primary care practitioners by ten percent or more in the next ten years? Input from attendees, which can be found online at www.gwdc.org/publications/ PrimaryCareGrantInput.pdf, can be summarized in four major categories: 1) population changes and needs, 2) higher education challenges, 3) provider changes and needs, and 4) healthcare delivery changes and needs. Attendees pointed out the increased rate of aging in rural communities and warned that the healthcare needs of seniors may be difficult to address in some communities. Some communities are seeing significant growth in minority populations. High rates of uninsured plague some areas. Many healthcare training programs are at capacity in Minnesota, largely because of a shortage in clinical training sites especially in rural areas. Securing preceptors, who often work longer days and accept lower wages, is difficult. Colleges and universities are confronted with reduced student readiness, and tuition assistance and job placement are key issues for healthcare education stakeholders in Minnesota. Healthcare providers in rural Minnesota are also aging at a greater rate than providers in the metro area. Regional meeting participants talked of difficulties with recruitment, especially for specialists such as general surgeons, obstetricians (or family practice physicians providing obstetric services), and mental health professionals. Emerging healthcare professionals such as community health workers and community paramedics are projected to have a positive impact on access to health care, especially in rural and urban underserved areas. Regional meeting participants also talked about changes in the healthcare delivery system. The medical home model is gaining traction in Minnesota, and with it a stronger integration of primary care and other services (especially mental health and pharmacy). Minnesota s health reform efforts are leading a focus on health status, health outcomes and disparities. Health information technology and telehealth continue to help improve and shape access to patient information and services. In addition to meetings, there were key informant interviews with many healthcare experts within the state. These interviews allowed more in-depth discussion with content experts. A website was also created to solicit other input and to share input received. Utilizing all the information gathered, Minnesota s HRSA Primary Care Workforce Plan of 2012 was drafted and forwarded to the Steering Committee for approval. The Steering Committee approved the report s recommendations on September 19, 2011 and the final report was submitted to HRSA. While no additional funding from HRSA is currently available to implement the strategies outlined in this plan, it is hoped that this report and its recommendations will serve as a valuable resource for Minnesota. 2 Primary Care Workforce Planning Grant Draft Report Page 24 of 81

Needs Assessment Minnesota has a plethora of data related to its healthcare workforce. Data sources include state agencies, associations, licensure boards, and educational institutions, among others. These data provide a picture of the state s healthcare workforce needs. demographics Evaluating data from the Census, the State Demographer, and the Department of Health, it becomes clear that Minnesota s population is aging and increasingly diverse. Aging Minnesota s population continues to grow older. Between 2000 and 2030, the portion of the state s population that is 65 and older is expected to increase from 12 percent to 24 percent. This is the fastest-growing age group in Minnesota, and the people in this group use far more physician services than their younger counterparts. 1 The next most rapidly growing age group includes those over 85 years. This trend is disproportionately affecting rural Minnesota. As of 2007, only 10 percent of the population was 65 and older in the seven-county metro area compared to counties beyond the Twin Cities region where 15 percent of the population was 65 years and older. Minnesota s population continues to grow older. Between 2000 and 2030, the portion of the state s population that is 65 and older is expected to increase from 12 percent to 24 percent. Diversity Minnesota s composition in terms of race, ethnicity, and nationality is also changing dramatically. In 2005, 11.8 percent of all refugees entering the United States arrived in Minnesota. Forty percent of all immigrants to Minnesota in 2005 came from Africa; 28 percent came from Asia. 2 Minnesota is home to the United States largest population of Somali residents (approximately 29,000), and has the ninth largest population of African immigrants nationally. Minnesota has the second largest Hmong immigrant population in the United States. The greatest increase has occurred among the Hispanic/Latino population, which grew from 53,884 to 143,382 (166 percent) during the 1990s. 3 According to the State Demographer s office, Minnesota ranked among the states with the most rapid growth in the Hispanic/Latino population. According to the 2000 Census, 81,074 Minnesotans identified themselves as American Indian or Alaskan Native alone or in combination with other races. Twenty-three percent (18,397) of American Indians in Minnesota live on one of the 14 reservations or associated trust lands in the state. Page 25 of 81 Governor s Workforce Development Council 3

growth Minnesota s population is expected to continue to grow in size and diversity over the next several decades, and accessible healthcare services are likely to be a quality of life consideration for new residents arriving in Minnesota. The State Demographer s office has projected that Minnesota s population will grow to over 6 million by 2035. Most of the growth is projected to come from continued migration from other states and countries. Recent national health rankings suggest that Minnesota s status as a leader in health is in jeopardy; in overall rankings, the state has fallen from first in 2006 to sixth in 2009. health outcomes and disparities Recent national health rankings suggest that Minnesota s status as a leader in health is in jeopardy; in overall rankings, the state has fallen from first in 2006 to sixth in 2009. 4 Although Minnesota ranks first in outcomes, its ranking in the determinants of health has fallen to seventh. Minnesota s generally high health status rankings hide significant health disparities, especially among minority populations.» African Americans in Minnesota are 63 percent more likely to experience premature death than Whites.» Residents in non-urban areas in Minnesota are 31 percent more likely to experience premature death than residents in the fringe counties of large metropolitan areas. 5» A report published by the Commonwealth Fund in 2007 rated Minnesota 38th overall in equity rankings in health care. This poor ranking was a result of large disparities among minority groups, specifically Asian Americans and Native Americans living in both urban and rural areas. 6» From 2001-2005, infant mortality for White infants in Minnesota was 4.4 per 1,000 births. The rate for African American infants was 9.2. The rate for Native American infants was 10.3. healthcare workforce According to the Health Resources and Services Administration s State Health Workforce Profiles 7, selected highlights regarding Minnesota s health workforce include:» More than 250,300 people were employed in the health sector in 2000. This represents 9.6 percent of Minnesota s total workforce, and is above the national rate of 8.8 percent.» More than 9,500 physicians were actively practicing in Minnesota in 2000, equating to 194 physicians per 100,000 residents. This ration is slightly lower than the national ratio of 198.» In 2000, Minnesota had 76 active primary care physicians per 100,000 residents, higher than the national rate of 69.» Medical schools in Minnesota graduated 275 new physicians in 1999-00.» There were 711 physician assistants practicing in Minnesota in 2000, which was equal to the national rate of 14.4 physician assistants per 100,000 residents. 4 Primary Care Workforce Planning Grant Draft Report Page 26 of 81

» There were more than 54,900 licensed registered nurses in Minnesota in 2000, with more than 47,000 employed in nursing. There were 954.6 registered nurses per 100,000 residents in 2000.» In 2000, there were 1,208 nurse practitioners, equal to 24.5 per 100,000 residents. This was below the national rate of 33.7.» There were 3,522 dentists, 3,410 dental hygienists, and 4,620 dental assistants practicing in Minnesota in 2000. All per capita ratios were above national rates.» There were 462 psychiatrists, 2,950 psychologists, and 11,620 social workers in Minnesota in 2000. health provider ShortageS Over the last six years, the healthcare industry has witnessed workforce shortages in a number of occupations. These shortages have lessened with the onset of recession in 2007, though health care was not hit as hard as most other sectors of the economy. The healthcare industry as a whole had 5,850 vacancies during the fourth quarter of 2009, with a median starting wage of $11.18 an hour. Nearly one in five jobs openings in Minnesota was in the healthcare industry. 8 Health professional workforce shortages exist throughout the state. As of July 2010, 52.9 percent of Minnesota counties carried a full or partial Health Professionals Shortage Area (HPSA) designation in primary care, 80.5 percent in mental health, and 49.4 percent in dentistry. 9 minnesota health professional Shortage areas (hpsa) and medically underserved areas (mua) Shortage area designation Primary Care HPSA (7/10) Dental Care HPSA (7/10) Mental Health HPSA (7/10) number of full County designations number of partial County designations total designations/ total Counties percent designations 19 27 46/87 52.9% 31 12 43/87 49.4% 70 0 70/87 80.5% MUA (7/10) 23 40 63/87 72.4% primary Care physicians A physician providing primary care is typically the first point of consultation for a patient; primary care is ongoing, rather than episodic. Roughly half of active physicians in Twin Cities Area counties are trained in primary care disciplines. Primary care accounts for a larger share of the physician workforce in other parts of the state, with the exception of Olmsted County (home of the Mayo Clinic), where only 28 percent of physicians report a primary care specialty. The percentage of physicians in primary care is highest in the most agricultural, least urbanized parts of the state: the Southwest, Northwest and North Central regions. percent of physicians in primary Care Statewide 50.9% Twin Cities Area 50.3% St. Cloud Area 62.9% Olmsted County 28.0% Southeastern Minnesota 67.4% Mankato Area 54.5% Willmar Area 76.0% Southwestern Minnesota 83.2% West Central Minnesota 71.9% Northwestern Minnesota 83.3% North Central Minnesota 73.4% Northeastern Minnesota 61.1% Page 27 of 81 Governor s Workforce Development Council 5

physician assistants Growth in the number of physician assistants has greatly outpaced growth in physicians. In July 2009, Minnesota had 1,371 licensed physician assistants, nearly three times the number 10 years earlier. In comparison, the number of licensed physicians increased only 28 percent from 1999 to 2009. As a result, the ratio of licensed physicians to physician assistants fell from 32 to 14 between 1999 and 2009. registered nurses and nurse practitioners As of June 2008, Minnesota had 77,950 licensed registered nurses (RN), a 19 percent increase since 2002. Not all of these RNs are actively working in Minnesota; some are retired or not working as RNs, and some work or practice in other states. Based on survey responses and licensing data from the Minnesota Board of Nursing, the Office of Rural Health and Primary Care estimates about 56,700 RNs were practicing at least part time at Minnesota practice sites in 2007. Using the July 1, 2007 population estimate for Minnesota, 56,700 RNs equate to 1,091 active RNs per 100,000 people. 10 The Minnesota Department of Employment and Economic Development projects a 23.8 percent increase in registered nursing jobs between 2009 and 2019. The Minnesota Department of Employment and Economic Development projects a 23.8 percent increase in registered nursing jobs between 2009 and 2019. nurse PrActitioners About five percent of registered nurses report practicing in a certified advanced practice category. About half of these were nurse practitioners, followed by registered nurse anesthetists, clinical nurse specialists and nurse-midwives. Nurse 80,000 60,000 40,000 20,000 73,790 projected Change in minnesota s working population (age 15 to 64), 2010 to 2035 18,580 45,180 0 2010-2015 2015-2020 2020-2025 2025-2030 2030-2035 -860-20,000-21,350 6 Primary Care Workforce Planning Grant Draft Report Page 28 of 81

practitioners and clinical nurse specialists are certified in a number of specialty areas.» The most common specialty areas among nurse practitioners were family nursing (30 percent), adult nursing (27 percent), women s health (15 percent), gerontology (15 percent) and pediatrics (14 percent).» The most common specialty areas among clinical nurse specialists were adult psychiatric/mental health nursing (27 percent) and medical-surgical nursing (23 percent). aging healthcare workforce Minnesota s State Demographer projects the working age population (15 to 64 years of age) of Minnesota to grow at about 2.5 percent between 2010 and 2015. Then, by 2015, workforce growth will slow dramatically as members of the baby boomer generation, currently the largest share of the workforce, begin to retire (see chart on page 6). For individuals considered to be in the prime of their working life (age 25 to 44) labor force growth is projected to increase between 2010 and 2035, but at declining rates. Overall, the largest growth in the labor force between 2010 and 2035 will be for individuals aged 65 and over, with a growth rate above 120 percent. 11 The aging population has significant implications for the healthcare industry in Minnesota. While the demand for healthcare services will increase, the healthcare industry will see significant retirements and fewer people entering the workforce. The age distribution of Minnesota s primary care providers shows approximately 30 percent of nurse practitioners and family physicians are 55 or older. 40% 30% age distribution of minnesota s primary Care providers Physician Assistants Median Age = 38 N=1,323 Family Physicians Median Age = 48 N=2,599 Nursing Practitioners Median Age = 51 N=2,180 The aging population has significant implications for the healthcare industry in Minnesota. While the demand for healthcare services will increase, the healthcare industry will see significant retirements and fewer people entering the workforce. 20% 10% 0% < 35 years 35-44 years 45-54 years 55-64 years > 65 years Page 29 of 81 Governor s Workforce Development Council 7

The median age of many key healthcare professionals practicing in Minnesota also points toward an aging healthcare workforce, particularly for nurse practitioners. 12» Family Physicians, median age 48» Nurse Practitioners, median age 51» Physician Assistants, median age 38 Of particular concern is the number of practicing healthcare professionals under 35 who plan to stop practicing in Minnesota. When replying to questions about practice longevity on the optional survey that accompanies license renewal, 19 percent of Minnesota s practicing physicians statewide said they plan to stop practicing in Minnesota within the next five years. Twenty six percent of physicians located in rural areas plan to discontinue their practice in the same time period. The following table demonstrates responses from key professional types. Of particular concern is the number of practicing healthcare professionals under the age of 35 who plan to stop practicing in Minnesota. 13 percentage of practicing providers with plans to Stop practicing in mn within 5 or fewer Years (2008 data) Statewide metro micro rural <35 Years old Physicians 19 19 21 26 26 Registered Nurses 18 18 18 18 20 educational CapaCitY Minnesota has two publically-funded systems of higher education: the University of Minnesota (U of M) and the Minnesota State Colleges and Universities (MnSCU). In addition, Minnesota has many private colleges which play important roles in the education of healthcare professionals. When looking at healthcare awards (based on CIP Code 51), it is clear that MnSCU educates the majority of baccalaureate and sub-baccalaureate graduates, and the U of M and private colleges educate a large percentage of graduate degree students. Sector Less than 2-Year Other Public 2-Year Private 2-Year Private 4-Year # of inst. minnesota ipeds Completions by Sector fiscal Year 2008 Subbacc. healthcare awards bacc. grad. total % of total total awards total % of total 3 165 0 0 165 1.1% 1,317 1.6% 0 0 0 0 0 0% 37 0.0% 9 1,058 0 52 1,110 7.4% 2,417 3.0% 26 554 916 1,583 3,053 20.3% 28,942 35.3% MnSCU 35 8,086 795 154 9,035 59.9% 34,576 42.2% U of M 3 22 414 1,276 1,712 11.4% 14,619 17.8% total 76 9,885 2,125 3,065 15,075 100% 81,908 100% 8 Primary Care Workforce Planning Grant Draft Report Page 30 of 81

the university of MinnesotA The University of Minnesota (U of M) is the only public higher education system with the authority to educate physicians, dentists, pharmacists and other post-graduate degrees including any doctor of philosophy. The U of M has a large baccalaureate nursing program and confers advanced practice nursing degrees. The Medical School includes more than 920 medical students and more than 800 residents and fellows, along with 1,600 Medical School faculty physicians and scientists. The University has a nationally-recognized rural physician program which admits 55 students each year. Students study two years in Duluth before transferring to the Twin Cities to complete their M.D. More than half of graduates who enter through the Duluth program enter family practice residencies. The U of M s School of Nursing confers Bachelor of Science in Nursing (B.S.N.), Master of Nursing (M.N.), post-master s Doctor of Nursing Practice (D.N.P.), and doctor of philosophy (Ph.D.). The School s 2009 enrollment was 460 pre-licensure, 56 professional, and 336 graduate students. From 2009 to 2010, the University increased its enrollment in advanced practice nursing from 55 to 108, an increase of 96 percent. Minnesota s Area Health Education Center (AHEC) supports the U of M s health professions schools by building on programs that place and support health profession students in rural clinical locations throughout the state. There are five regional AHECs in Minnesota with an additional AHEC planned for southeastern Minnesota in 2010. Each AHEC has a unique role based on its region and the directives of its independent board. university of minnesota enrollment in advanced practice nursing programs, 2009-2010 program 2009 2010 total Adult Geriatric 6 16 22 NP Geriatric CNS 1 0 1 Family NP 11 15 26 Informatics 2 5 7 Integrated Health 9 5 14 Health Systems Admin 3 12 15 Nurse Midwife 6 9 15 Pediatric CNS 1 3 4 Pediatric NP 6 16 22 Psychiatric CNS 4 5 9 Public Health 2 4 6 Public Health/ Adolescent Women s Health NP 3 2 5 1 13 14 Adult CNS 0 3 3 total matriculates 55 108 163 MinnesotA state colleges AnD universities Minnesota State Colleges and Universities (MnSCU) is the largest public higher education system in Minnesota. With 7 state universities and 25 community and technical colleges located in 54 communities throughout the state, MnSCU provides geographic access to healthcare programs ranging from certificates to Doctor of Nursing Practice. MnSCU graduates approximately 70 percent of Minnesota s new nurses each year and has significantly increased its capacity over the past 10 years in response to the nursing workforce needs of Minnesota s providers. In addition, MnSCU graduates approximately 50 percent of Minnesota s allied health students each year. MinnesotA s PrivAte colleges Minnesota s private colleges are integral to educating Minnesota s future healthcare workforce. Augsburg College has the only physician assistant program in Minnesota with a historical class size of 22 (note: this has increased through this grant planning process and period to 30 students, an increase of 36 percent). It has recently been announced that St. Catherine University intends to start a physician assistant program which will have capacity to enroll 20 students. The College of St. Scholastica, St. Catherine University, Bethel College, and Augsburg College graduated approximately 25 percent of Minnesota s post-master s students in 2009 (see chart on page 10). Page 31 of 81 Governor s Workforce Development Council 9

2009 post-baccalaureate nursing awards School master s degree post-master s Certificate doctor s degree total WSU 37 0 6 43 Scholastica 27 9 4 40 St. Kate s 22 0 0 22 Moorhead 9 0 5 14 Mankato 13 0 4 17 Metro 23 0 4 27 UMN 155 0 32 187 Bethel 13 0 0 13 Augsburg 18 0 0 18 total 317 9 55 381 Note: Excludes Walden University, which reports data in Minnesota but whose students are predominently located outside Minnesota. 10 Primary Care Workforce Planning Grant Draft Report Page 32 of 81

Goals and Strategies The target goal associated with this planning grant and process was straightforward and focused: to achieve an increase of 10 to 25 percent of primary care providers by 2022 This equates to the following increases: 2009 baseline 10% 25% Physician 3,660 366 915 Nurse Practitioner 2,180 218 545 Physician Assistant 1,380 138 345 total 7,120 712 1,805 Specific strategies for each discipline are outlined below. Strategies range from expanding successful Minnesota initiatives and models to redesign of curricula to expanding programs. Clearly the success of these strategies hinge on a variety of factors. In today s economy, with state and federal budgets constrained and future reductions expected, the ability to access the financial resources required to increase the primary care workforce is uncertain. So while increased educational capacity, recruitment, and retention of providers is a part of the puzzle, Minnesota is leading the nation with reforms to keep its population healthier and reduce the demand for health care services. The development of healthcare homes in Minnesota is part of the ground-breaking federal health reform legislation passed in May 2008. The legislation includes payment to primary care providers for partnering with patients and families to provide coordination of care. The healthcare home model is an approach to primary care in which primary care providers, families, and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions. The use of healthcare homes will enable Minnesotans to receive interprofessional, high-quality care in a delivery model which does not rely as heavily on the primary care provider. While increased educational capacity, recruitment, and retention of providers is a part of the puzzle, Minnesota is leading the nation with reforms to keep its population healthier and reduce the demand for health care services. Historically, hospitals, clinics, and other healthcare employers have been able to fund workforce development initiatives, but these funds have been severely reduced in recent years. The requirement that financial resources show a return on investment is a challenge for workforce development projects that need to be measured over several years rather than a short-term budget period. As reimbursement to providers is expected to remain a target for cost-cutting, this financial pressure is not likely to ease in the near future. Page 33 of 81 Governor s Workforce Development Council 11

So while the future is uncertain, it is important to identify and address primary care workforce issues through this comprehensive planning process. Strategies range from expanding successful Minnesota initiatives and models to redesign of curricula to expanding programs. physicians The University of Minnesota is one of the top three schools in the country in producing primary care physicians. Its commitment to primary and rural care is well-known and unquestioned. There are several categories of strategies, however, that could have some impact on the primary care workforce. financial/alignment 1. Bridge the compensation gap between primary care providers and those in specialty roles to encourage students to choose primary care. (Primary care providers, particularly physicians, are paid significantly less than those in specialty roles.) 2. Advocate for payment equity in state and federal healthcare payments. (Minnesota providers are reimbursed less than their counterparts in the rest of the country, even while being recognized for providing care of the highest-quality.) 3. Advocate for reinstatement of reduced Medical Education Research Cost funds which were reduced in Minnesota s current biennium budget. curriculum 4. Integrate primary care content into the medical school curriculum whenever possible. 5. Integrate community-based research and health equity concepts into residency programs. 6. Support the summer externship program in family practice for first and second year medical students. 7. Grow the Rural Physician Associate Program (RPAP) through replication at the Mayo Medical School. 8. Identify financial support for the MetroPAP program so that it can expand its capacity to give students experience in primary care to underserved populations. 9. Develop mentorship programs for students with practicing or retired primary care physicians. 10. Support interprofessional education and care delivery models. external factors/recruitment 11. Make increased use of loan forgiveness and employer-based sponsorships and sign-on bonuses to attract new physicians to high-need vacancies and areas. 12. Increase the number of foreign-certified physicians obtaining Minnesota licensure. This includes support for the Preparation for Residency Program, a seven-month training program that works to improve the competitiveness of foreign-certified physicians when applying for residency slots. 12 Primary Care Workforce Planning Grant Draft Report Page 34 of 81

13. Increase efforts to use the full 30 J1 Visa waiver slots available each year. 14. Maximize the establishment of healthcare homes in Minnesota to extend the reach/impact of all primary care providers. 15. Recruit osteopathic and allopathic physicians from outside Minnesota to fill vacancies. 16. Establish partnerships such as the Future Doctors program and the Fairview Health Services/St. Olaf College collaboration to support and encourage students to enter primary care. 17. Utilize mentoring programs that begin in middle school. experiential/residency ProgrAM capacity 18. Increase financial support to maintain and grow primary care residency programs, especially when hospitals are under increased financial pressure. (One of the most limiting factors in medical education is the availability of residency programs/slots. This bottleneck hampers growth of programs including traditional medical education and foreign-certified physicians who must complete a residency program.) physician assistants The expanded use of physician assistants will be critical to the provision of primary care in the future. The only PA program in Minnesota is located at Augsburg College. This program recently increased its enrollment from 22 to 30 students. A second program is being planned at St. Catherine University. Strategies to support PA programs, increase utilization, and emphasize primary care are outlined. ProgrAM capacity/support 1. Encourage programs to utilize clinical experience scheduling technology (StudentMax) to increase scheduling efficiency and to identify additional clinical site opportunities. 2. Support the planned program at St. Catherine University through provision of clinical education, student referral, and integration into the healthcare education community. 3. Establish a primary care-focused PA program in greater Minnesota within the public college and university system. The expanded use of physician assistants will be critical to the provision of primary care in the future. 4. Provide housing support for students choosing a clinical experience in Greater Minnesota. utilization 5. Conduct a survey to learn more about the utilization of physician assistants in Minnesota including their use within family practice physician offices. 6. Establish a consulting team to educate providers on use of physician assistants. 7. Improve marketing of the profession to the public and potential students. 8. Recruit former Minnesota graduates back to practice in Minnesota. Page 35 of 81 Governor s Workforce Development Council 13

PriMAry care/specialty focus 9. Integrate primary care focus/content into curricula to encourage more graduates to choose primary care roles. 10. Develop more roles and opportunities for PA practice in various settings, especially primary care and behavioral health. nurse practitioners There are a number of initiatives underway in Minnesota which will increase the number of nurse practitioner graduates. One of the most recent is the designation of the Minnesota Action Coalition by the Future for Nursing: Call for Action initiative supported by the Robert Wood Johnson Foundation and AARP. The purpose of the Action Coalition is to implement the Institute of Medicine (IOM) Future of Nursing recommendations. Other strategies are centered around curriculum, external factors, and experiential learning. curriculum 1. Consistent with the IOM Future of Nursing recommendations, increase the ease with which students can progress along a seamless pathway from practical nursing through doctoral education. 2. Revisit admission requirements to admit more rural and underrepresented students who are most likely to work in high-need settings. 3. Strategically identify placement of programs such as the 2-year NP mobility program to meet community needs. external factors 4. Recruit RNs and other employees in long-term care settings to become Geriatrics NPs. 5. Remove scope of practice limitations. 6. Develop funding streams to place a Geriatric Nurse Practitioner in every long term care facility to hasten workforce and system redesign and reduce demand. experiential learning 7. Increase clinical training capacity through improved coordination between sites and educational programs. Implement with technology (StudentMax) and dedicated staff at a central location, and at education programs and employers. 8. Utilize Health Care Homes as clinical/internship sites for nursing students to highlight primary care and nursing s role in primary care. 9. Explore different models of clinical precepting such as a two-to-one student-to-preceptor model to double the number of clinical placements. other ConSiderationS Recognizing that the number of primary care practitioners is not the sole indicator of a highly-effective healthcare system, several other goals were identified as critical to ensuring that Minnesota has the healthcare workforce it needs in the future. 14 Primary Care Workforce Planning Grant Draft Report Page 36 of 81

DAtA collection While Minnesota has a vast array of data related to healthcare work, it is located in multiple organizations, collected for different time frames, general in nature when more detailed would be beneficial, and inconsistent among data sources. Therefore, a strong need exists for a coordinated health workforce planning effort to bring focus, transparency, and clarity to this critical future workforce need. Strategies to increase data accessibility and usability include: 1. Create an ongoing healthcare data task force to identify data gaps, needs, and comparability. 2. Improve response to the surveys that accompany license renewal of many health disciplines. 3. Implement licensure or other registration requirements for additional, critical health disciplines. 4. Continue participation in data standardization efforts through licensure boards and the federal government. 5. Create a data clearinghouse or centralized point of contact for healthcare workforce-related data questions/needs. AllieD health Primary care providers are part of a healthcare workforce that consists of many other professionals, including specialists, registered nurses, support staff, and allied health disciplines. It is imperative that the entire workforce be highly-skilled and appropriately utilized. 1. Establish an incumbent worker career pathway program to advance workers from low-skilled to high-skilled healthcare roles. 2. Integrate allied health programs into the clinical education scheduling database (StudentMax). 3. Conduct allied health workforce studies to identify areas of greatest need. recruitment/retention/career exploration All sectors of the economy are competing for a shrinking pool of working-age adults. The healthcare sector needs to actively encourage students and adults to choose this sector. In addition, retention of employees is a critical factor in sustaining the workforce. Primary care providers are part of a healthcare workforce that consists of many other professionals. It is imperative that the entire workforce be highly-skilled and appropriately utilized. 1. Support pre-employment healthcare academies to prepare individuals for health careers. 2. Develop a Careers in Aging Services campaign to recruit individuals into careers in caring for the elderly. 3. Develop an employee recognition program to reward stellar employees. 4. Hold a Provider Wellness Conference to prevent burn-out and emphasize self-care. 5. Actively pursue HRSA Health Care Occupations Program (HCOP) grants to recruit students into NP, PA and APN programs. Page 37 of 81 Governor s Workforce Development Council 15

6. Utilize www.iseek.org to support career exploration to all age groups. 7. Work within elementary and secondary schools to showcase healthcare careers. 8. Establish longitudinal mentoring and support programs for students. rural needs Access to appropriate, timely, and high-quality care for all Minnesotans regardless of where they live is necessary to ensure a healthy citizenry. 1. Develop housing support mechanisms for students in rural clinical sites. 2. Publicize National Health Service Corps loan repayment options. 3. Utilize rural FQHCs and federally-qualified rural health clinics for clinical rotations. 4. Advocate for additional rural FQHCs in Minnesota. Diversity As Minnesota continues to become increasingly diverse and research continues to show improved health outcomes from a diverse workforce, it is important that Minnesota has a supportive and effective educational system and work environments. 1. Hold statewide conferences to identify and share best practices related to the education of diverse students. 2. Establish forums for discussion of issues related to healthcare diversity. 3. Work within communities to support selection of and success in health careers. financial The financial pressures are well-known. In addition to the financial strategy recommendations outlined above, there are other steps that could be taken to shore up financial resources. 1. Maintain and grow loan forgiveness programs for primary care providers. 2. Healthcare programs are among the most expensive programs in higher education. Support for these programs is imperative. next StepS/ConCluSion While no additional funding is currently available to implement the strategies outlined in this plan, the expertise and partnerships within Minnesota s healthcare workforce community will work to implement these strategies as resources become available. The plan will continue to serve as a resource for the state and will be reviewed and updated as needed. 16 Primary Care Workforce Planning Grant Draft Report Page 38 of 81

Endnotes 1 Demographics of an Aging Population, Minnesota Department of Health, Fall 2005. 2 Eliminating Health Disparities Legislative Report, Minnesota Department of Health, January 2007. 3 Minnesota Demographers Office (1990) and 2000 US Census 4 America s Health Ratings: A Call to Action for People and Their Communities. United Health Foundation, 2009 5 Ibid. 6 Ibid. 7 State Health Workforce Profiles, Highlights (Minnesota). National Center for Health Workforce Analysis, Health Resources and Services Administration. Retrieved from http:// bhpr.hrsa.gov/healthworkforce/reports/statesummaries/minnesota.htm July 7, 2010. 8 Ibid. 9 Office of Rural Health and Primary Care, Minnesota Department of Health. 10 Minnesota s Registered Nurses Facts and Data 2008. Office of Rural Health and Primary Care, Minnesota Department of Health. Retrieved from http://www.health.state.mn.us/ divs/orhpc/pubs/workforce/rn08.pdf on July 12, 2010. 11 Healthcare Industry in Minnesota. Minnesota Department of Employment and Economic Development, June 2010. 12 Office of Rural Health and Primary Care, Minnesota Department of Health, July 2010. 13 Ibid. Page 39 of 81 Governor s Workforce Development Council 17

4/28/2012 MN Office of Higher Education Health Sciences Workforce Data Health Sciences Awards Conferred by Post Secondary Institutions 1994 2010 8,000 7,000 Certificates Number of Awards 6,000 5,000 4,000 3,000 2,000 1,000 Associate Master's Bachelor's Doctorate Year Page 40 of 81 1

4/28/2012 Awards by Level and Program Career Clusters MN Institutions 2009 10 Awards Conferred by Level and Program Career Clusters by Minnesota Institutions, 2009 10 Certificates Associate degree Bachelor's degree Master's degree Doctorate Total Agriculture, Food & Natural Resources 523 300 1,381 153 36 2,393 Architecture and Construction 1,471 691 258 162 2,582 Arts, Audio/Video Tech, & Communications 288 944 3,720 220 44 5,216 Business Mgt., Marketing, & Finance 1,442 2,160 7,700 4,070 348 15,720 Education and Training 176 185 2,590 8,165 790 11,906 Government and Public Administration 1,083 544 34 1,661 Health Science 6,952 5,226 4,104 4,240 1,399 21,921 Hospitality and Tourism 300 467 70 837 Human Services 1,784 359 2,319 1,522 120 6,104 Information Technology 202 745 857 535 26 2,365 Law and Corrections 825 1,237 957 236 941 4,196 Liberal Arts, Languages, History 196 5,283 4,012 358 65 9,914 Manufacturing and Transportation 1,744 835 187 25 2,791 Science, Technology, Engineering, and Mathematics 35 196 5,782 802 371 7,186 Total 15,938 18,628 35,020 21,032 4,174 94,792 Source: U.S. Department of Education, IPEDS Completion Survey Certificate Awards 09 10 8% Health Science 5% 3% Human Services (cosmetology) Manufacturing and Transportation 9% 44% Construction 9% Business Law and Corrections 11% 11% Agriculture Other Page 41 of 81 2

4/28/2012 Associate Degrees 09 10 12% Health Science 4% 28% Liberal Arts 4% Business 5% Law and Corrections 7% Arts & Communications 12% 28% Manufacturing and Transportation Information Technology Other Bachelor s Degrees 09 10 Business 14% 22% STEM 7% Health Science 7% Liberal Arts, Languages & History 17% Arts & Communications 11% Education and Training 11% Human Services 12% Other Page 42 of 81 3

4/28/2012 Master s Degrees 09 10 6% 3% 3% 4% Education Health Science 7% 39% Business Human Services 12% STEM Government Information Technology 20% Other Doctorates 09 10 8% 2% 3% 4% 34% Health Science Law and Corrections Education 9% STEM Business 12% Human Services 23% Liberal Arts, Languages & History Other Page 43 of 81 4

4/28/2012 Award Levels by Race/Gender 09 10 Race Certificate Associate Bachelors Masters Doctorate American Indian 132 M 16 F 118 36 M 3 F 33 11 M 2 F 9 16 M 4 F 12 4 M 4 F 0 Asian 343 M 61 F 282 172 M 2 F 147 69 M 10 F 59 93 M 24 F 69 37 M 18 F 29 Black 771 M 199 F 710 Hispanic 213 M 35 F 178 Two or more 23 races No gender data 345 M 93 F 252 71 M 35 F 178 14 No gender data 101 M 19 F 82 25 M 1 F 0 10 No gender data 373 M 52 F 321 80 M 12 F 68 4 No gender data 37 M 15 F 22 12 M 8 F 4 3 No gender data White 4801 M 721 F 4080 4516 M = 552 F 4064 1810 M 197 F 1613 1948 M 262 F 1676 898 M 334 F 564 Total Awards 6283 5154 2026 2514 991 Page 44 of 81 5

History of Medical Education and Research Costs (MERC) In 1993, recognizing that medical education and research are vital activities affecting not only the health care community but also the health of every citizen and the economy of the entire state, the Minnesota Legislature directed the Commissioner of Health to examine medical education and research costs in order to assess how health care reform and health care market changes had affected the financing of these important activities. The Department's study of medical education and research continued for three years, and culminated in the report, Medical Education and Research Costs (MERC): A Final Report to the Legislature (February 1996). A key recommendation in the report was the creation and funding of a Medical Education Trust Fund in Minnesota. Largely as a result of this report, the Medical Education and Research Costs (MERC) Fund was established in 1996. The purpose of the fund was and is to compensate hospitals and clinics for a portion of the costs of clinical training. These costs had traditionally been covered by teaching facilities charging higher rates for patient care; however, in a highly competitive market, third party payers had become less willing to pay the higher charges at teaching institutions, leaving teaching facilities at a competitive disadvantage. The MERC Fund was funded for the first time in 1997, with $5 million from the General Fund, $3.5 million from the Health Care Access Fund, and $9.3 million in federal Medicaid funds, for a total of approximately $17.8 million distributed to teaching facilities in 1998. Since 1997, the financing for MERC has shifted several times, first to the medical education endowment established by the 1999 legislature with funds from the one-time tobacco settlement, and later to a 2.5 cents per pack cigarette tax, which was shifted to MDH in 2003. Currently, funds for the MERC distribution come from cigarette tax revenues, a carveout of medical education funds from the Prepaid Medical Assistance Program/Prepaid General Assistance Medical Care program, and federal Medicaid matching funds obtained by the Department of Human Services. The formula governing the MERC distribution has also changed over the years. Beginning in 2004, when funds from the PMAP/PGAMC carveout were combined with MERC funds in a single annual distribution, the formula changed to reflect the combination of the two programs; the formula used from 2004 to 2007 was based 67% on relative teaching costs at each facility and 33% on relative public program volume at each facility. In 2004 and 2005, training sites that hosted fewer than 0.5 FTE trainees from an eligible clinical training program were eliminated from the distribution, as were any advanced practice nursing programs sponsored by organizations not part of the Minnesota State Colleges and Universities (MnSCU) system, the University of Minnesota Academic Health Center, the Mayo Clinic, or the Private College Council. At the same time, the formula was also altered so that 90% of available funds were distributed on a formula basis and 10% went directly to sponsoring institutions to be distributed at their discretion to eligible training sites or to small sites. The 10% discretionary fund continued through 2007. Page 45 of 81

New legislation in 2007 changed the distribution formula. Instead of the 67% education/33% relative public program revenue formula, the formula is based 100% on relative public program revenue. 2011 MERC Distribution Changes - Current Status: The MERC/PMAP formula is based solely on relative public program volume. Training sites whose relative public program volume is more than 0.98% of the total get a supplemental grant of 20%; the supplemental payment is made by reducing the MERC grants for those below the 0.98% line. The MERC statute also included several direct payments, which are made to the UM AHC ($1.8M), the UM Dental School ($2.075M), and the University of Minnesota Medical Center, Fairview ($1.475M). MERC changes adopted during 2011 special legislative session: Funding changes: The estimated total amount available for distribution in FY12-13 is $31.5M, and in FY14-15 the estimated total amount is $44.3M. The direct payments previously made to the University of Minnesota s Academic Health Center, the University of Minnesota Medical Center Fairview, and the University of Minnesota Dental School were eliminated. Formula changes: A new minimum grant amount was established for MERC. Any training site whose total grant would be less than $1,000 was eliminated from the distribution. Page 46 of 81

Executive Summary Bringing Health Care to the Heartland: An Evaluation of Minnesota s Loan Forgiveness Programs for Select Health Care Occupations April 2007 Office of Rural Health and Primary Care P.O. Box 64882 St. Paul, MN 55164-0882 www.health.state.mn.us Phone: (651) 201-3838 Toll free: (800) 366-5424 Fax: (651) 201-3830 TDD: (800) 627-3529 Page 47 of 81

2 Executive Summary: An Evaluation of Minnesota s Loan Forgiveness Programs In 1990, the Minnesota State Legislature created and funded a program to recruit physicians to practice in rural Minnesota. Since then the program has expanded to assist 564 physicians, nurses, nurse practitioners, nurse-midwives, physician assistants, clinical nurse specialists, pharmacists, dentists and allied health or nursing faculty in rural Minnesota or other high need locations such as nursing homes, intermediate care facilities for the mentally retarded, and dental practices serving more than 25 percent low income or public program patients. This is not the only tool the state uses to recruit health care providers to rural or high need occupations. Federal programs also support this effort by targeting limited federal loan repayment funds to Health Professional Shortage Areas through the state Loan Repayment Program. The Minnesota Department of Health-Office of Rural Health and Primary Care is responsible for the administrative direction and oversight of these Loan Forgiveness Programs. To this end a program evaluation was initiated to determine the effectiveness of the program, whether it was meeting its intended legislative purpose, and to identify potential administrative improvements. After almost 17 years of operation and growing from an annual state appropriation of $320,000 to $1.295 million in 2007, the Minnesota Loan Forgiveness Programs have also served over 300 health care facilities and educational institutions throughout the state. In the past seven years, Minnesota has invested a total of $7.789 million in the Loan Forgiveness Programs. Are these programs effective in meeting their goals? This study addressed the following questions: Are the programs effective in recruiting to each setting? Are the programs effective in retaining providers? What recruitment/retention challenges exist? When in education/training are decisions made on specialty/location? What opportunities exist for improvement? Between January and March of 2007, 405 program participants and 138 sponsoring facilities were contacted and asked to complete a three- to five-page evaluation survey. The response rate was high with an overall completion rate of 73 percent. Results were also compared to the last program evaluation, which was completed in 1999. Due to the nature of the program, most of the respondents were from rural Minnesota. Minnesota Department of Health-Office of Rural Health and Primary Care Page 48 of 81

3 Executive Summary: An Evaluation of Minnesota s Loan Forgiveness Programs Key findings 1. The Loan Forgiveness Programs were effective in recruiting health care practitioners into high need locations. The program was important to very important in recruiting staff to work in 57 percent of the sponsoring facilities. The program was important to very important in recruiting faculty to work in 25 percent of the sponsoring institutions. Since 2001, 326 health care providers and faculty have chosen rural or high need practice locations as a result of the Loan Forgiveness Programs. 2. A majority of health care practitioners who complete their service obligation remain in similar practice settings in Minnesota. Of the responding physicians who completed their service obligation, 86 percent remained at their sponsoring facilities. Of the responding midlevel practitioners who completed their service obligation, 76 percent remained at their sponsoring facility after completion. Of the dentists who completed their service obligation, 52 percent remained at their sponsoring facility after completion. 93 percent of nurses who completed their service obligation remained at their sponsoring facility after completion. 3. Sponsoring facilities (placement sites) vary in their dependence on the Loan Forgiveness Program as a recruitment/retention tool. Primary care and specialty clinics with less than 20,000 patient visits in 2006 valued the program the most (60 percent). Nursing home survey respondents valued the program the least (20 percent) as a recruitment and retention tool, primarily because many were unaware of it. Adequate salary, availability of nurses and of primary care physicians were the top recruitment challenges faced by sponsoring facilities and educational institutions. Nursing homes (86 percent) and educational institutions (83 percent) reported adequate salary for staff as the primary recruitment challenge compared to pharmacies (40 percent) and dental clinics (30 percent) that have the fewest challenges with adequate salary for staff recruitment. Signing bonuses, relocation expenses or other loan repayment funds are used by over 75 percent of the responding sponsoring Minnesota Department of Health-Office of Rural Health and Primary Care Page 49 of 81

4 Executive Summary: An Evaluation of Minnesota s Loan Forgiveness Programs facilities. No educational institutions that responded to the survey provided signing bonuses or relocation expenses to their health occupation faculty. The Loan Forgiveness Programs are reaching some of the facilities most challenged with recruitment difficulties small primary care practices located in greater Minnesota and outside of any major population center (Rochester, Duluth, St. Cloud, Moorhead, Mankato). Of the responders from the sponsoring facilities, 76 percent were aware of at least one of the Loan Forgiveness Programs by name. Only 17 percent of the survey respondents use the program as a recruitment tool for their health care facility. 4. Students are considering health occupations specialties/practice locations at earlier stages in their education, which can be prime marketing opportunities. Of the responding physicians, 71 percent decided to specialize in primary care between high school and their third year of medical education. Of the responding physicians, 44 percent decided to practice in a rural area between high school and their third year of medical education. Of the responding midlevel practitioners, 55 percent decided to practice in a rural area between high school and completion of their undergraduate education. 5. Opportunities exist to improve the program. Four recommendations are made, based on the survey results and program review. Target marketing to high school and undergraduate students in health occupations training. Invest in additional communication materials and marketing efforts that promote the Loan Forgiveness Programs and the Health Care Safety Net Workforce Development Pipeline in Minnesota. Maximize the use of technology to increase awareness and track program outcomes. Request an opinion from the Attorney General s Office on the tax deductibility of the service obligation funds in light of several recent tax rulings. Minnesota Department of Health-Office of Rural Health and Primary Care Page 50 of 81

5 Executive Summary: An Evaluation of Minnesota s Loan Forgiveness Programs In conclusion, the Loan Forgiveness Programs examined in this report and administered by the Minnesota Department of Health-Office of Rural Health and Primary Care are successfully meeting their program goals and increasing the number of health care providers and educators in rural Minnesota and specialty locations. The complete evaluation and more Minnesota Loan Forgiveness Program information is online at http://www.health.state.mn.us/divs/cfh/orhpc/loan/home.htm or call (651) 201-3838. If you require this document in another format, such as large print, Braille or cassette tape, call (651) 201-3838. Minnesota Department of Health-Office of Rural Health and Primary Care Page 51 of 81

Service Obligation All participants are responsible for securing their own eligible employment and must begin working no later than March 31 following completion of their required training program. Participants may complete their service obligation at more than one eligible location and may also transfer to another eligible facility during their obligation. Participants must agree to practice in an eligible geographic area, facility type, teaching area, patient group or specialty type in Minnesota at least 30 hours per week (12 credit hours or 720 hours per year for faculty) and for a minimum of three years. Award Amount Annual loan forgiveness awards are based on 15 percent of the average educational debt of recent graduates in each profession and the vacancy rate in the required geographic area, facility type, teaching area, patient group or specialty type. A participant s annual award amount is fixed at the time of selection. A participant may receive loan forgiveness benefits for a maximum of four years. Loan forgiveness awards are considered exempt from state and federal income taxes beginning after December 31, 2008. MN Workforce Work Group Background Reference Material for May 3, 2012 Detailed information is online at www.health.state.mn.us/divs/orhpc or contact Mohamed Samaha mohamed.samaha@state.mn.us 651-201-3870 800-366-5424 (MN only) The program helped relieve the burden of establishing my practice. Dentist serving public program patients P.O. Box 64882, St. Paul, MN 55164-0882 February 2012 Minnesota Health Professional Loan Forgiveness Programs I think this is one of the few good programs in place to recruit graduates into primary care. Christa Waymire, M.D. Glencoe Regional Health Services Page 52 of 81

Purpose Minnesota s Loan Forgiveness Program recruits and retains health care professionals to needed areas and facilities within Minnesota. Loan forgiveness is an important benefit for health care professionals as well as health care facilities and communities experiencing a shortage of access to primary health care services. MN Workforce Work Group Background Reference Material for May 3, 2012 Eligible Health Professions Physician Primary Care Residents (Family Practice, Internal Medicine, OB/GYN, Pediatrics, Psychiatry Pharmacist Students/Residents in a Pharmacy Program Licensed Pharmacists Midlevel Practitioners Nurse Practitioner Students Certified Nurse Midwife Students Nurse Anesthetist Students Advanced Clinical Nurse Specialist Students Physician Assistant Students Minnesota Practice Locations Rural area that is defined as a small rural or isolated rural area according to the four category classifications of the Rural Urban Commuting Area system developed for the United States Health Resources and Services Administration. Urban Physicians Only: Underserved urban community in Minneapolis or St. Paul designated as a primary medical care health professional shortage area (HPSA) or medically underserved area (MUA), or with medically underserved populations (MUPs). Nurse Licensed Practical Nurse Students Registered Nurse Students Licensed Nursing Home or Intermediate Care Facility for the Developmentally Disabled The program is essential to maintaining nursing home RNs. Participating Registered Nurse Faculty Students studying to become Allied Health Care Instructors or Nursing Instructors Post-secondary Allied Health Care or Nursing Program Application and Selection The application cycle begins July 1 and ends December 1. Selections are made based on suitability for practice as indicated by personal and professional experience and training noted on an application, as well as other relevant factors. The number of applicants selected for participation varies annually and is contingent upon state funding. Dentist Students/Residents in a Dental Program Licensed Dentists Twenty-five percent of annual patient encounters are public program or sliding fee scale patients Complete information is online at: www.health.state.mn.us/divs/orhpc Page 53 of 81

4/27/2012 1940 s - Nurse Midwives CNM) and Nurse Anesthetists (CRNA) Advanced Practice Registered Nursing: Emerging Trends in Education and Practice 1954 psychiatric nursing 1960 s APRN as a primary care provider CNM 244 CNS 520 CRNA 1,654 CNP 2,974 Page 54 of 81 1

4/27/2012 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collecting and an improved information infrastructure. Recommendation # 1 Remove Scope of Practice Barriers Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends actions for the following entities: State legislatures Congress Centers for Medicare and Medicaid Services Office of Personnel Management Federal Trade Commission and Antitrust Division of the Department of Justice Parity with other disciplines Degree conferred to reflect higher level of education Master s continues to increase in didactic and clinical hours Health care system is complex and needs redesign requires visionary leadership and high level health care management skills Need for clinical faculty 1. Scientific underpinnings for practice 2. Organizational and systems leadership for quality improvement and systems thinking 3. Clinical scholarship and analytical methods for evidencebased practice 4. Information system/technology and patient care technology for improvement and transformation of health care 5. Health care policy advocacy 6. Interprofessional collaboration for improving patient and population outcomes 7. Clinical prevention and population health for improving nation s health 8. Advanced nursing practice Page 55 of 81 2

4/27/2012 Improving population health requires effective health care systems leaders and problem solvers Expert managed care requires effective evidence-based practice interdisciplinary collaboration Responsiveness to increasingly complex health care requires increased education and regulatory reform Page 56 of 81 3

Office of Rural Health and Primary Care Health Workforce Analysis Program Minnesota s Registered Nurses Facts and Data 2008 The Office of Rural Health and Primary Care (ORHPC) asks registered nurses to answer questions about their employment status and the nature of their practices each year when they renew their licenses. Response to the survey is voluntary and does not affect license renewal. Numbers of Registered Nurses As of June 2008, Minnesota had 77,950 licensed registered nurses (RN), a 19 percent increase since 2002. Not all of these RNs are actively working in Minnesota. Some are retired or not working as RNs, and some work or practice in other states. About 66,150 licensed RNs had Minnesota mailing addresses, but not all work in Minnesota. Responses from the ORHPC survey make possible an estimate of the number of RNs actually working in Minnesota. Based on survey responses and licensing data from the Minnesota Board of Nursing, the Office of Rural Health and Primary Care estimates about 56,700 RNs were practicing at least part time at Minnesota practice sites in 2007. Using the July 1, 2007, population estimate for Minnesota, 56,700 RNs equate to 1,091 active RNs per 100,000 people. For explanation of this estimate, see the methodological note at the end of this report. The U.S. Bureau of Labor Statistics estimated 52,690 RN jobs in Minnesota in May 2007. This lower estimate equates to 1,013 RNs per 100,000 people, compared to a national figure of 818. Minnesota ranked eighth in the number of RNs per capita. All data reported below is for RNs who worked at least part time at a primary practice site in Minnesota at the time they completed the survey. P.O. Box 64882 St. Paul, MN 55164-0882 (651) 201-3838 http://www.health.state.mn.us November 2008 Page 57 of 81