-
Pathways to Rural Primary Care Practice:
Research Findings on What Works from
Rural PREP*
3RNet Annual Conference
September 25, 2019
Davis Patterson, PhD
*Collaborative for Rural Primary care Research, Education, and
Practice
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Overview
What is Rural PREP?
Research findings:• Medical school commitment to rural primary
care
o Predictors of rural primary care output
o Rurally targeted admissions
• Nurse practitioner readiness for rural practice
• (if time) K-16 programs to promote health careers for
rural students
Discussion
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Acknowledgments and Disclaimer
This research was supported by the Bureau of Health
Workforce (BHW), Health Resources and Services
Administration (HRSA), U.S. Department of Health and Human
Services (HHS) under cooperative agreement
#UH1HP29966. The information, conclusions and opinions
expressed in this presentation are those of the authors and
no
endorsement by BHW, HRSA, or HHS is intended or should be
inferred.
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Rural PREP research team
University of Washington School of Medicine
Davis Patterson, PhD
Holly Andrilla, MS
David Evans, MD
Eric Larson, PhD
Susan Skillman, MS
Samantha Pollack, MHS
Andrew Jopson, MPH
Lindsay Pysson, MPA
Juan Pablo Paredes
Ohio University Heritage College of Osteopathic Medicine
Randall Longenecker, MD
University of North Dakota School of Medicine & Health
Sciences
David Schmitz, MD
Washington State University College of Nursing
Louise Kaplan, PhD, ARNP, FANP-BC, FAANP, FAAN
-
Collaborative for Rural Primary care Research, Education, and
Practice
...to improve and sustain rural health through community
engagement
and research in rural primary care health professions
education.
-
Rural PREP aims and methods
Project period:
07/2016
to
06/2021
HRSA AU-PCTE AimsConduct research
on rural primary care
health professional
education/training
and promote
research
Disseminate
research, tools,
evidence-based
practices
Build a community
of practice to
promote
enhancement of
rural primary care
training
Rural PREP
research portfolio
Microresearch
Rural PREP Grand
Rounds and
Webinars
Research Design
& Dissemination
Studios
-
Rural PREP research portfolioK-16 students How Can We Strengthen
Rural Opportunities in K-16 Education
to Promote Primary Care Health Careers?
Physicians
Medical
students
Measuring the Commitment of Medical Schools to Rural Primary
Care
How Do U.S. Medical Schools Use Targeted Admissions to
Increase the Number of Doctors in Rural Areas?
Residents How Can We Support Rural-centric Residency Programs
as
Unified ACGME Accreditation Approaches in 2020?
Are Family Physicians Trained in Small Rural Residencies of
Comparable Quality to Family Physicians Overall?
Nurse practitioner
students
Routes to Rural Readiness: Enhancing Clinical Training
Experiences for Nurse Practitioner Practice in Rural Primary
Care
Physician assistant
students
Routes to Rural Readiness: Enhancing Clinical Training
Experiences for Physician Assistants
Primary care teams in
practice
The Impact of Telepsychiatry Services on the Training of
Rural
Primary Care Teams in Integrated Behavioral Healthcare Teams
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Where will the next rural providers come from?
-
“Prime the pump and open the spigot.”
1970s – increase class sizes + new schools with
primary care missions
2006 – AAMC calls for increased enrollment
• 30% increase in enrollment since 2002
New osteopathic schools
• 162% increase in osteopathic slots
-
Conventional wisdom about the rural
health workforce
Recruiting students from a rural
background is the most important way
to build a rural workforce.
-
Conventional wisdom meets reality:
not EITHER/OR but BOTH/AND
Rural students alone won’t be enough:
• Not enough rural students with preparation needed
for health careers
• Some rural students will be “lost” to urban practice
• Rural exposure needed for all students/trainees:
o Need to stimulate urban students to think about rural
practice (esp. those with rural interest)
o Need urban providers with rural competencies
Education and practice transformation needed,
not just producing more doctors
-
Medical School Commitment to
Rural Primary Care
-
Background
Educating physicians for rural and/or primary care practice
- a stated mission of many medical schools
Study purpose: explore indicators of medical school
commitment to rural primary care by identifying:
1) schools’ output of rural primary care physicians
2) organizational and educational factors that predict rural
primary care output
Compare multiple factors with statistical controls
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% of Graduates in Rural Primary Care Practice*
Top 20% of schools: 3.5% to 11.4% of 2001-10 graduates
*According to RUCAs as of 2016, using AMA Physician Masterfile
data
0%
2%
4%
6%
8%
10%
12%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45
47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89
91 93 95 97 99 101
103
105
107
109
111
113 115
117
119
121
123
125
127
129
131
133
135
137
139
141
143
U of Pikeville Kentucky College of Osteopathic Medicine
U of North Dakota School of Medicine and Health Sciences
U of South Dakota Sanford School of Medicine
U of Kansas School of Medicine
Des Moines U College of Osteopathic Medicine
West Virginia School of Osteopathic Medicine
U of New England in Maine College of Osteopathic Medicine
U of Mississippi School of Medicine
U of Kentucky College of Medicine
East Tennessee State U James H. Quillen College of
Medicine
U of Minnesota Medical School - Twin Cities
U of Arkansas for Medical Sciences
A.T. Still U Kirksville College of Osteopathic Medicine
U of Nebraska Medical Center College of Medicine
Kansas City U of Medicine and Biosciences College of
Osteopathic Medicine
The Brody School of Medicine at East Carolina U
Oklahoma State U Center for Health Sciences College of
Osteopathic Medicine
Michigan State U College of Human Medicine
Joan C. Edwards School of Medicine at Marshall U
U of Louisville School of Medicine
Mercer U School of Medicine
U of Washington School of Medicine
The Robert Larner College of Medicine at the U of Vermont
U of Colorado School of Medicine, Anschutz Medical campus
U of New Mexico School of Medicine
Edward Via College of Osteopathic Medicine, Virginia Campus
U of Iowa Roy J. and Lucille A. Carver College of Medicine
Lake Erie College of Osteopathic Medicine - Bradenton
Campus
Audrey and Theodor Geisel School of Medicine at Dartmouth
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Significant associations with rural primary care output
Potential predictors of % of grads in rural primary care
practice
(significant bivariate associations shaded in green) Value (all
schools)
+ Rural clinical experiences 67.4%
Publicly funded 56.9%
Multiple campuses 34.0%
+ Rural program† 25.7%
+ Rural curriculum (non-clinical) 25.7%
+ Rural faculty titles 21.5%
+ Rural leadership titles 21.5%
+ Osteopathic 15.3%
Admissions preference - rural background 7.6%
+ Stated rural mission 6.9%
+ Admissions preference - rural interest/intent 5.6%
+ Rural location (RUCAs) 4.2%
In-state matriculants 65.3% (median)
- NIH research funding (mean: 2007-2010) $39.3 million
(median)
+ Rural scholarly output, papers 2000-17‡ 1 (median)
†E.g., track, pathway, certificate, longitudinal integrated
clerkship, campus
‡Peer-reviewed papers on U.S. rural primary care, health
professions, or population health
-
Medical school predictors of high production of
rural* primary care physicians
Top 20%: 3.5% to 11.4% of 2001-10 graduates in rural primary
care
*According to RUCAs as of 2016, using AMA Physician Masterfile
data
0%
2%
4%
6%
8%
10%
12%
1 3 5 7 9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
53
55
57
59
61
63
65
67
69
71
73
75
77
79
81
83
85
87
89
91
93
95
97
99
101
103
105
107
109
111
113
115
117
119
121
123
125
127
129
131
133
135
137
139
141
143
1. Rurally located school
2. “Rural” in the school’s mission statement
3. Osteopathic school
4. More scholarly output on rural health topics
-
?
Rural location
Rural mission
Osteopathic
Rural
scholarly
output
Rural
primary care
physicians
What predicts rural scholarly output?
-
Rural faculty
titles +
Rural
curriculum +
NIH funding +
Multiple
campuses +
Allopathic +
Rural location
Rural mission
Osteopathic
Rural
scholarly
output
Rural
primary care
physicians
What predicts rural scholarly output?
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Implications
Key predictors of rural primary care practice include
• fixed characteristics of medical schools (rural,
osteopathic)
• factors within a school’s control to change (rural
mission,
scholarship)
Educational investments to support production of rural
primary
care physicians could be effectively tailored to local
constraints
and opportunities:
• Invest in new rural and osteopathic schools. $$$$$
• Expand class sizes in top producers. $$$
• Target existing and new schools: make rural a part of the
mission and invest in rurally-oriented infrastructure. $ -
$$$$
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Rurally Targeted Admissions to Address
the Physician Workforce Gap
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Rurally Targeted Admissions to Address
the Physician Workforce Gap
Surveyed and interviewed Deans of Admissions
at U.S. medical schools
• Does your school have rurally targeted
admissions?
• Characteristics of applicants targeted?
• Does the admissions process differ?
• Recruitment strategies?
-
Rural Targeted Admissions to Address the
Physician Workforce Gap
69% of responding schools reported rurally targeted
admissions
-
Strategies used by the 69% of medical schools that say
they recruit students likely to practice in rural areas
(2018)
83.3%
28.2%
62.1%
22.4%
35.7%
7.2%
89.9%
47.7%
57.5%
42.9%
68.2%
45.5% 46.6%
20.5%
Career Exploration,Career Counseling,and/or Mentorship
AcademicEnhancement
AdmissionsPreparation*
ArticulationAgreement*
High schools
Community & technical colleges
Four-year universities
Post-baccalaureate programs
*Not asked about high schools
-
Strategies used by the 69% of medical schools that say
they recruit students likely to practice in rural areas
(2018)
83.3%
28.2%
62.1%
22.4%
35.7%
7.2%
89.9%
47.7%
57.5%
42.9%
68.2%
45.5% 46.6%
20.5%
Career Exploration,Career Counseling,and/or Mentorship
AcademicEnhancement
AdmissionsPreparation*
ArticulationAgreement*
High schools
Community & technical colleges
Four-year universities
Post-baccalaureate programs
*Not asked about high schools
-
Strategies used by the 69% of medical schools that say
they recruit students likely to practice in rural areas
(2018)
83.3%
28.2%
62.1%
22.4%
35.7%
7.2%
89.9%
47.7%
57.5%
42.9%
68.2%
45.5% 46.6%
20.5%
Career Exploration,Career Counseling,and/or Mentorship
AcademicEnhancement
AdmissionsPreparation*
ArticulationAgreement*
High schools
Community & technical colleges
Four-year universities
Post-baccalaureate programs
*Not asked about high schools
-
Strategies used by the 69% of medical schools that say
they recruit students likely to practice in rural areas
(2018)
83.3%
28.2%
62.1%
22.4%
35.7%
7.2%
89.9%
47.7%
57.5%
42.9%
68.2%
45.5% 46.6%
20.5%
Career Exploration,Career Counseling,and/or Mentorship
AcademicEnhancement
AdmissionsPreparation*
ArticulationAgreement*
High schools
Community & technical colleges
Four-year universities
Post-baccalaureate programs
*Not asked about high schools
-
Nurse Practitioner Readiness
for Rural Practice
-
Similarities and differences among rural NPs, PAs, and
physicians (primary care)
Doescher MD, Andrilla CHA, Skillman SM, Morgan P, Kaplan K.
The
contribution of physicians, physician assistants, and nurse
practitioners
toward rural primary care. Med. Care 2014;52(6):549-56.
• While NPs, PAs, and physicians aren’t substitutes for each
other, where
scope of practices overlap, productivity is similar (esp. if
control for age,
sex and location).
• In addition, NPs and PAs see more Medicaid patients.
-
Background
Estimates suggest up to 75% of rural primary care
services could be provided by NPs and PAs
Compared with urban NPs, rural NPs*:
more often practice to the full extent of their legal
scope
are more satisfied with their work
more often said they planned to stay in their jobs
*According to an analysis of the 2012 National Sample Survey of
NPs
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Objectives
Survey and interview NP primary care program directors
and rural clinical training site personnel to:
• Examine characteristics of rural-oriented NP
education programs
• Identify factors that promote student participation in
rural clinical experiences
• Describe successful strategies to recruit/retain NPs in
rural practice
-
How important to your NP program’s mission/goals
is preparing NPs for providing primary care for
rural populations?
*Preliminary results as of 9/2019
84.9%
12.9%
2.2%
69.0%
27.6%
3.4%
57.9%
36.8%
5.3%
69.2%
30.8%
0.0%
77.3%
20.1%
2.6%
Very Important Somewhat Important Not Important
Family (n=93)
Adult-Gerontology (n=29)
Pediatrics (n=19)
Women's Health (n=13)
Total Respondents(n=154)
NP Program Type
-
Student recruitment
62%-76% of programs actively recruited students
from rural areas.
72%-83% actively recruited students with an intent to
practice in rural or rural-serving areas.
-
Finding rural sites for clinical training is a
barrier for NP programs
Among NP primary care education programs with a
rural mission:
• 43% are not consistently able to offer rural clinical
sites
to students
Two biggest barriers to rural clinical training:
• 77% - competition with other NP programs for rural
clinical training sites
• 72% - competition with other (non-NP) health
professional education programs for rural clinical
training sites
-
Other barriers to placing students in rural sites
Student resistance
Cost of travel
Shortages of available primary care providers
Productivity issues
Health systems limiting NP students
Payment of preceptors
-
Facilitators of schools’ rural placements
HRSA funding for students – ANEW* grants
Students want to work in the area where the rural
clinic is located
Alumni in the clinical sites
Personal connections with the faculty and
communication between programs and preceptors
*Advanced Nursing Education Workforce Program
-
Characteristics of successful rural sites
(reported by NP programs)
Committed preceptor both to the practice and to
teaching/education
Commitment from clinic/health care system to NP
student education and hiring
NP is from the rural area, known to the community
Patients willing to see students
Loan repayment is available
-
Clinical site perspectives on what works for
successful NP recruitment and retention
Loan repayment programs
Opportunities for communication and community among
practicing NPs
Strong clinical mentors and thorough onboarding/orientation
for new hires
Dedicated administration time and referral support person
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Implications for rural clinical training
Health system consolidation in rural areas:
Distant corporate decision-makers may not support
rural training, view as a cost.
Loss of clinical training programs is a disincentive
for rural clinicians motivated to be educators.
-
Implications for rural clinical training
Health system consolidation in rural areas:
Distant corporate decision-makers may not support rural
training,
view as a cost.
Loss of clinical training programs is a disincentive for
rural
clinicians motivated to be educators.
Opportunities to support rural clinical training?
How can we create incentives to develop more
sites?
How can we collaborate to share available
sites?
-
Discussion
Questions? Comments?
What new or additional information on building a rural
primary
care workforce would help you in your work?
-
Connect
Davis Patterson: [email protected]
Follow us on social media: @ruralprep
Website: https://ruralprep.org/
Join our mailing list: [email protected]
mailto:[email protected]://ruralprep.org/mailto:[email protected]
-
Feedback: help us improve!
http://bit.ly/3RNET_2019
“3RNet_2019”
http://bit.ly/3RNET_2019
-
Rural K-16 Educational
Strategies to Promote
Rural Health Careers:
Preliminary Findings
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Study objectives
• Identify programs for rural K-16 preprofessional students
to
promote health careers (especially primary care)
• Describe strategies used
• Uncover evidence (if any) on the effectiveness of programs
or
specific strategies
Key partner: National AHEC* Organization
Survey of 252 AHECs and 55 AHEC program offices
*Area Health Education Center
-
K-16 strategies for rural students Yes, we
currently do
Motivation or Health Career Awareness 95.0%
Healthcare Exposure 89.9%
Mentorship 61.8%
Academic Enhancement 46.3%
Academic Partnerships 44.1%
College/Professional School Readiness 42.2%
Health Professions School Application
Preparation41.9%
Research 24.2%
-
K-16 strategies for rural students Yes, we
currently do
Yes, we have
done in the
past 3 years
but NOT
currently
Motivation or Health Career Awareness 95.0% 5.0%
Healthcare Exposure 89.9% 4.3%
Mentorship 61.8% 11.0%
Academic Enhancement 46.3% 11.2%
Academic Partnerships 44.1% 8.8%
College/Professional School Readiness 42.2% 8.9%
Health Professions School Application
Preparation41.9% 12.5%
Research 24.2% 6.8%
-
K-16 strategies for rural students Yes, we
currently do
Yes, we have
done in the
past 3 years
but NOT
currently
No, we have
not done in the
past 3 years
Motivation or Health Career Awareness 95.0% 5.0% 0.0%
Healthcare Exposure 89.9% 4.3% 5.0%
Mentorship 61.8% 11.0% 21.3%
Academic Enhancement 46.3% 11.2% 36.6%
Academic Partnerships 44.1% 8.8% 39.0%
College/Professional School Readiness 42.2% 8.9% 43.0%
Health Professions School Application
Preparation41.9% 12.5% 37.5%
Research 24.2% 6.8% 52.3%
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Education levels of participants by strategy
16% 15%
6%
14%
9% 8%
0%
8%
34%31%
10%
30%
26%22%
0%
8%
98% 99%
74%
91% 92%94%
67%
52%
57%
50%49%
52% 51%
61%
55%
36%
58%
Motivation or HealthCareer Awareness
HealthcareExposure
Mentorship AcademicEnhancement
AcademicPartnerships
College/ProfessionalSchool Readiness
Health ProfessionsSchool Application
Preparation
Research
Grades K-5 Grades 6-8 Grades 9-12 Community/technical college
4-year college/university
-
Education levels of participants by strategy
16% 15%
6%
14%
9% 8%
0%
8%
34%31%
10%
30%
26%22%
0%
8%
98% 99%
74%
91% 92%94%
67%
52%
57%
50%49%
52% 51%
61%
55%
36%
58%
Motivation or HealthCareer Awareness
HealthcareExposure
Mentorship AcademicEnhancement
AcademicPartnerships
College/ProfessionalSchool Readiness
Health ProfessionsSchool Application
Preparation
Research
Grades K-5 Grades 6-8 Grades 9-12 Community/technical college
4-year college/university
-
Strategies Yes, we
currently do
Yes, we have
done in the
past 3 years
but NOT
currently
No, we have
not done in the
past 3 years
Motivation or Health Career Awareness 95.0% 5.0% 0.0%
Healthcare Exposure 89.9% 4.3% 5.0%
Mentorship 61.8% 11.0% 21.3%
Academic Enhancement 46.3% 11.2% 36.6%
Academic Partnerships 44.1% 8.8% 39.0%
College/Professional School Readiness 42.2% 8.9% 43.0%
Health Professions School Application
Preparation41.9% 12.5% 37.5%
Research 24.2% 6.8% 52.3%
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Why activities discontinued in past 3
years
• Change in program priorities
• Loss of external funding
• Loss of internal funding
-
Several mentioned HRSA’s de-emphasis
of “pipeline” programs
“The shift in HRSA away from supporting pipeline initiatives has
really
impacted our office’s ability to encourage K-12 students to
pursue
healthcare careers.”
“If the goal of HRSA programs is to increase the diversity
and
distribution of health care providers in rural, frontier and
under-served
areas, then HRSA has to recognize that activities and programs
that
fill the "pipeline" are necessary... Rural, frontier and
underserved
students will NEVER end up as AHEC Scholars if they're not
exposed
to the wide variety of health care programs in high school.”
-
Next steps
Further analysis of survey data
Interviews with select program leaders
What questions should we be asking?
-
Connect
Davis Patterson: [email protected]
Follow us on social media: @ruralprep
Website: https://ruralprep.org/
Join our mailing list: [email protected]
mailto:[email protected]://ruralprep.org/mailto:[email protected]
-
Feedback: help us improve!
http://bit.ly/3RNET_2019
“3RNet_2019”
http://bit.ly/3RNET_2019
-
Bonus slides
-
Primary care coding
'FMP' Family Medicine/Preventive Medicine
'FSM' Family Practice/Sports Medicine
'FP' Family Practice
'FPG' Family Practice/Geriatric Medicine
'GP' General Practice
'IM' Internal Medicine
'IMG' Internal Medicine - Geriatrics
'IPM' Internal Medicine - Preventive Medicine
'ISM' Internal Medicine - Sports Med
'MPD' Internal Medicine - Pediatrics
'PD’ Pediatrics
-
Candidates for intervention?(schools just below the top 20%)
Rural (1): Ohio U Heritage College of Osteopathic Medicine
Rural mission (1): Florida State University College of
Medicine
Top 1/3 rural scholarly output (9):
Newer schools
AACOM, AAMC
Medical College of Wisconsin
Oregon Health & Science University
School of Medicine
Penn State College of Medicine
University of Alabama at Birmingham
School of Medicine
University of Illinois College of
Medicine
University of Missouri School of
Medicine
University of Tennessee Health
Sciences Center College of
Medicine
University of Wisconsin School of
Medicine and Public Health
West Virginia University School of
Medicine
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Admissions Process Strategies to Target Applicants
Likely to Practice in Rural Areas (n = 92)74.7%
38.2%
30.0%
21.4%18.8%
11.2%6.8%
Secondaryapplicationcontains
questions tohelp identify
target applicants
Preferentialscoring ininterviewscreening
Preferentialscoring in final
admissionsdetermination
Modify MCATcutoffs
Modify GPAcutoffs
Separateinterviews thanother applicants
Differentinterviewquestions
-
Institutional Strategies to Target Applicants
Likely to Practice Rural (n = 92)
75.6%72.0%
37.1%
20.2%
Rural physicians part ofinterview team
Rural physiciansinvolved in targeted
strategy
Offer Targeted FinancialAid
Reserve slots in eachentering class
-
Pathways in US NP Education
Primary care NPs (for purposes of the
study)
Family NP (across the life span)
Women’s Health Care NP
Pediatric NP Primary Care
Pediatric NP Acute Care
Adult–Gero Primary Care NP
Adult-Gero Acute Care NP
Psychiatric Mental Health NP
Neonatal NP
