The Healthcare Workforce in Rural Pennsylvania

The Healthcare WorkforceIn Rural Pennsylvania

Prepared by

Pennsylvania Rural Health Association

June 2004

Limitations of Report:

Data used in tables and text are taken from different reports. Reports from

the same source for the same time periods are sometimes inconsistent

without an explanation of differences.

In Pennsylvania Department of Health surveys of RNs, LPNs, dentists and

dental hygienists, there are differences in totals between license renewals

and totals reported employed in Pennsylvania because of employment

status, place of residence and other variables that affect employment in

healthcare in Pennsylvania.

More abundant data is available for the nursing workforce because of the

high visibility caused by shortages, particularly in hospitals over the last two

years.

There is a notable lack of up-to-date information on the healthcare workforce

both at a national and local level.

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PRHA’s The Healthcare Workforce In Rural Pennsylvania

June 2004 Page 55

Table of Contents

Introduction ................................................................................................................................................. 1

Hospitals, Long-Term Care Facilities, and Community Health Centers ........................................... 3–4

Healthcare Workforce Profile of Pennsylvania .................................................................................. 5–21

Nursing ............................................................................................................................. 7–12

Registered Nurses ............................................................................................................... 7

Licensed Practical Nurses ................................................................................................... 9

Nurse Practitioners ........................................................................................................... 11

Nurse-Midwives ......................................................................................................... 11–12

Dentistry ......................................................................................................................... 12–14

Dentists ............................................................................................................................. 12

Dental Hygienists ............................................................................................................. 13

Dental Assistants ............................................................................................................... 14

Physician Assistants ....................................................................................................... 15–16

Pharmacy ........................................................................................................................ 16–18

Pharmacists ....................................................................................................................... 16

Pharmacy Technicians ...................................................................................................... 17

Public Health .................................................................................................................. 18–19

Mental Health ....................................................................................................................... 20

Direct Care ........................................................................................................................... 20

Federal and State Funded Programs for Recruitment and Retention ........................................... 21–24

Other Initiatives Aimed at Improving the Healthcare Workforce in Pennsylvania ...................... 25–27

References ............................................................................................................................................ 28–53

Citations ......................................................................................................................... 29–30

Appendix A: Supporting Information ............................................................................. 31–43

Appendix B: Number of Selected Healthcare Provider Schools in PA in Rural Counties .... 44

Appendix C: Considerations for Healthcare Workforce Issues ...................................... 45–53


June 2004 Page 1

IntroductionThe purpose of this report is to determine the effect

of workforce shortages on rural healthcare systems

through a systematic review of healthcare workforce

information. The Pennsylvania Rural Health Association

assigned an Ad Hoc Task Force to study issues affecting

the healthcare workforce in rural Pennsylvania counties.

This includes assessing identified problems and offering

considerations.

A review of national and state reports demonstrate

that healthcare workforce in Pennsylvania mirror those

being faced by other states including:

A decreasing number of students in educational programs for

selected healthcare categories that are key to maintaining

comprehensive and quality patient care in healthcare

systems.

High vacancy rates (above 10 percent) for Registered

Nurses, Imaging Technicians, Pharmacists, Licensed

Practical Nurses and Nursing Assistants.

Discontent with work environment leading to short term

retention among selected categories of healthcare workers.

Low percentages of minority populations in all professional

healthcare provider groups.

Dissatisfaction with the effects of new and emerging

healthcare system structures on the more traditional

personalized approach to care of patients.

Aging of nursing and dental care workforces.

Citations: 8,9,10,11,17, and Appendix C: local and national

reports, pages 47, 48, and 53.

Important questions the Task Force considered:

1. How are these problems more critical for rural healthcare

systems and populations in Pennsylvania;

2. How will these shortages compound the problems already

unique to rural places including:

Lack of support systems for medical and allied health

personnel;

Lack of equipment, technology and medical/surgical

specialty providers;

Policy and regulations that limit the scope of practice

for non-physician providers of care; and

Lack of social and educational opportunities.

3. What are some of the solutions already in place, or planned for,

by local communities affected by the shortages;

4. Will national and state legislative initiatives provide short and

long-term solutions to the problem, or will they only be palliative

in nature;

5. What process is necessary to implement recommendations that

have been successful in selected rural areas of our state, or in

other states with large rural populations.

These questions will not be fully answered in this

report, but are the beginning of a process that will assist the

Pennsylvania Rural Health Association in further assessing

the rural healthcare workforce.■

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(Rural = population density less than the state's 274 persons per square mile)

Pennsylvania's Rural and Urban Counties

Data source: U.S. Census BureauPrepared by: Center for Rural Pennsylvania Urban Rural

Elk

Tioga

Erie

York

Potter

Centre

Berks

Bradford

Butler

LycomingClinton

Bedford

Pike

Warren

Clearfield

McKean

Crawford

Luzerne

Indiana

Blair

Somerset

Wayne

Fayette

PerryBucks

Lancaster

Mercer

FranklinChester

Clarion

Schuylkill

Monroe

CambriaHuntingdon

Venango

Allegheny

Greene

Washington

Jefferson

Westmoreland

Adams

Mifflin

Forest

Fulton

Dauphin

Armstrong

Susquehanna

Beaver

Sullivan

Juniata

Union Carbon

Columbia

Lehigh

Snyder

Cumberland

WyomingCameron

Lebanon

Montgomery

Lackawanna

Lawrence

Northumberland

Northampton

Delaware

Montour

Philadelphia


June 2004 Page 3

Hospitals, Long-Term Care Facilities, andCommunity Health Centers

To understand healthcare workforce issues in

Pennsylvania, it is necessary to have a sense of the need

for healthcare services in the state. One of the ways to

determine this is to document the numbers and locations of

already established major healthcare facilities and the

availability of qualified workers to staff them.

Facilities identified as located in rural counties are

based on the definition adopted by the Center for Rural

Pennsylvania using 2000 census data. This definition, based

on population density, identifies 48 of Pennsylvania’s 67

counties as rural. These counties contain 3.4 million, or 28

percent, of the state’s 12.3 million residents (Appendix A

Maps, and B, Supporting Data).

Table 1: Hospitals and Healthcare Facilities in Pennsylvania (1, 3)

Type of facility Total number of Total number of Total number of Total number of setup and staffedfacilities in state setup and staffed facilities located in beds in facilities in rural counties

beds in state (2)

rural counties(included in total #)

General Hospitals 190 34,607 76 8,078

Psychiatric 25 4,603 5 93

LTC/Acute 14 715 2 70

Rehab 19 1 657 3 195

Children’s 7 874 0

Alcohol/Drug 4 299 beds + onefacility with unknown #

Podiatry 1 13 0

Dental 1 6 1 6

Eye 1 40 0

Oncology 1 74 0

OB/Gyn 1 214 0

Ambulatory Surgery Centers 90 17

Licensed Long-Term 770 (90 hospital- 95,083 256 (43 hospital-basedCare Facilities

(3)based LTC facilities are LTC facilities are includedincluded in this number) in this number)

Notes:(1) Source: The Directory of Pennsylvania Hospitals and Ambulatory Surgery Centers: Pennsylvania Department of Health, Bureauof Health Statistics 2000-2001. (The Department of Health specifically disclaims responsibility for any analyses, interpretations orconclusions.) 1

(2) Set up and staffed beds may be the same as, or less than, the number of licensed beds in a facility.

(3) Source: The Directory of Pennsylvania Nursing Homes 2001 2, which provides basic information about long-term care facilities,licensed by the Department of Health 2.

Page 4 June 2004


Sources:

(1) Community Health Centers and Other Affiliated Clinical Sites in Pennsylvania,1997. Pennsylvania Office of Rural Health in Cooperation with the PennsylvaniaArea Health Education Center Program. 3

(2) Certified Medicare Rural Health Clinics are contained in Federal CommunityHealth Centers— not separate centers.

Table 2: Community Health Centers: Important sites forthe delivery of healthcare to rural residents (1)

Type PA Urban Rural

Federal Community Health Centers 103 76 27

Other community health centers 22 17 5

Federally-qualified health center look alike 11 11 0

Certified Medicare rural health clinics (2) 47 47

Migrant health canters 17 11 6

Healthcare for the homeless clinics 19 19 0

Health services to residents of public housing 3 3 0

HIV Ryan White healthcare centers 4 4 0

National Health Service Corps Sites 46 34 12


June 2004 Page 5

Healthcare Workforce Profile of PennsylvaniaThe majority of information on healthcare workers

contained in tables in this section is taken from the U.S.

Department of Health and Human Services (DHHS), Health

Services and Resources Administration (HRSA) State Health

Workforce Profiles Report published in 20004. All tables in

this report are from HRSA, unless otherwise noted. The table

is located on page 6.

Data comparing Pennsylvania to the DHHS Region III

and the nation are for the year indicated in the first column

of each table and are used as anchor data for further

comparisons or updates in the tables or in the text. One of

the limitations in compiling this report was the lack of up-to-

date information on the healthcare workforce. Even the 2000

HRSA report uses information from 1996 in some of its

tables.

Shortages of healthcare workers are not limited to

those included in this report. The table below indicates the

numbers and rank for 11 categories of healthcare profession-

als in Pennsylvania and the projected need to the year 2006.

Time and space limit the inclusion of all of these profession-

als in this report.

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Categories of Healthcare Workers

Nurses, including: Registered Nurses (RNs), Licensed Practical

Nurses (LPNs), Nurse-Midwives, (CNMs) and Nurse Practitioners

(NPs-often called Advanced Practice Nurse Practitioners

[APRNs]).

Dental healthcare professionals, including: Dentists, Dental

Hygienists and Dental Assistants

Physician Assistants

Pharmacists

Public health professionals

Mental health professionals including: Psychiatrists, Psycholo-

gists, Social Workers and Direct Service Workers

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June 2004 Page 7

RN Workforce Issues:

Eighty five percent of RNs employed in healthcare in Pennsylva-

nia work in urban areas containing 79% of the population and

15% work in rural areas containing 21%

Enrollments in schools of nursing, although increased over the

last two years, are still below those of five years ago

Increased need for state and federal scholarship and loan

repayment funds

Difficulty in obtaining clinical practice sites for students

Limited numbers of minorities in the nursing profession

Mandatory overtime

NCLEX pass rates in Pennsylvania are below the national

percentage pass rate for first-time test takers in the year 2000

Aging of RN workforce

Frequent turnover in hospital employment (retention)

Dissatisfaction with work environment

Lack of public acknowledgment or appreciation for contribution to

patient care

Lack of opportunity for advancement and salary increase

Understaffing in inpatient facilities

Lack of opportunity to participate in policy decisions

High vacancy rates in inpatient healthcare facilities

Limited career options available for advancement in hospital

nursing

Increased opportunities for RN employment in non-nursing

settings; for example: pharmaceutical companies, insurance,

managed care, and law firms.

Lack of educational opportunities

Negative feedback from nurses to the younger generation

Burnout

Citations: 7,9,10,11, 26 and Appendix C: local and national

reports, pages 47, 48, and 53..Source: U.S. Department of Health and Human Services(DHHS), Health Services and Resources Administration (HRSA)State Health Workforce Profiles Report published in 2000.

Note: Data collection by federal and state agencies on registerednursing is inconsistent. However, since 1996 there has beenminimal increase in the overall supply of nurses in Pennsylvania.

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Nursing:

There are different levels of personnel identified in the

nursing workforce. This report will address Registered

Nurses (RNs), Licensed Practical Nurses (LPNs), Nurse-

Midwives (CNMs) and Nurse Practitioners (NPs).

With all of the different levels of nursing practice,

issues relating to workforce shortages can make sense only if

the practice area or facility with the shortages is identified,

as well as the particular category of nursing personnel.

Recent publicity on the nursing workforce shortage has

focused on RNs in hospital settings. This report will focus on

nurses employed in institutional settings.

Registered Nurses—

The registered nurse population consists of different

levels of education including Diploma, Associate Degree,

Bachelor of Science, Masters, and Doctoral preparation.

After completing a basic program, a candidate must pass the

National Council Licensure Examination (NCLEX) to

become an RN. Passing this test allows an individual to

apply for licensure to practice as an RN in any state in the

nation. In Pennsylvania, the Pennsylvania State Board of

Nursing is the state agency that licenses all RNs to practice.

RN’s may specialize at the Master’s or Post Master’s

level to become Certified Registered Nurse Practitioners

(CRNP), Clinical Nurse Specialists (CNS), Certified Nurse

Anesthetists (CNA) or Certified Nurse Midwives (CNM).

Additional licensure is required to practice as a CRNP, CNA,

or CNM.

In most research on the RN nursing workforce, all of

the above levels are counted in aggregate statistics because

all must have a basic RN license to practice. This often

confuses the issue of workforce shortages in that all catego-

ries of RNs are not employed in inpatient healthcare

facilities giving direct care to patients.

Legal Definition: The Practice of Professional

Nursing (Registered Nurse): Diagnosing and treating human

responses to actual or potential health problems through such

services as case finding, health teaching, health counseling,

and provision of care supportive to or restorative of life and

well-being, and executing medical regimens as prescribed by

a licensed physician or dentist. The foregoing shall not be

deemed to include acts of medical diagnosis or prescription

of medical therapeutic or corrective measures, except as

performed by a certified registered nurse practitioner in

accordance with rules and regulations promulgated by the

Board ((1) amended December 9, 2002, P.L. 1567, No.206.)5

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Table 3: Registered Nurses (RNs)

RNs 2001 PA Region III US PA Rank

Number 160,149 311,670 2,558,874 3/50

Per 100,000 1,014.9 924.6 797.7 8/50

Percent employed 67% 70% 71% 34/50full-time nursing

Percent minority 5.2% 10%

Page 8 June 2004


Table 3 demonstrates several things:

Pennsylvania ranked eighth in the nation in the number of RNs

per 100,000 population, significantly higher than the national

average.

The percentage of the total numbers of RNs in the state

employed in nursing was significantly lower than the national

average.

A survey of RNs in 2002 by the Pennsylvania Depart-

ment of Health indicated that there is no significant growth

in the numbers of RNs in the state (approx. 166,116), nor the

percent employed in full-time nursing (69.2%). This survey

also indicates that approximately only 3% of the RNs in

Pennsylvania are of minority status.

Comments on RN Education:

Table 4 demonstrates a dramatic drop in the percentages of RN-

Diploma educated nurses in Pennsylvania between the years of

1996 and 2002; a slight increase in BSN preparation and a

significant increase in nurses with an Associate Degree. In

addition, over one fourth of the RNs have advanced certification.

This prepares them for work in specialty units within a hospital

setting or in ambulatory, primary care settings.

A report published in April 2003 on the status of nursing

education by the Pennsylvania Department of Health 8 indicates

the following:

1. There are 34 RN-BS, 27 RN-DIP, and 22 RN-AD

educational programs in Pennsylvania as of January

2003.

2. Approximately 17% of RN programs are located in rural

counties, but 21 counties do not have a registered nurse

program; 20 of these counties are defined as rural by the

1990 census definition.

3. Between 1995 and 2002 the number of RN nursing

education programs decreased in Pennsylvania by five RN-

DIP, and one RN-AD. This data in Pennsylvania mirrors the

shift in the nation away from diploma nursing.

4. After several years of declining enrollment, there was a

general increase in total enrollment in all four types of nurs-

ing education programs between 1999 and 2002, especially

between 2000 and 2002.

Another trend not indicated in any of the national or local

reports, but which is responsible for the decrease in diploma

RNs in the workforce, is that the majority of the nursing diploma

programs in Pennsylvania and the nation have affiliations with

colleges of nursing that award college credit for diploma nursing

courses. This enables the diploma nurse to continue towards an

associate or baccalaureate degree in nursing.

Selected Nursing Workforce Issues:

Aging of the current workforce in

Pennsylvania—The HRSA report indicates

that the percentage of RNs 40 years and

older in the Middle Atlantic Census

Division increased from 51 percent in 1986

to 63 percent in 1996. The Hospital &

Healthsystem Association of Pennsylvania

conducted a survey of member hospitals in

the year 2000 for age information on

nursing staff; 69 percent of the responding

hospitals reported the average age was

greater than 40 years.9

The Pennsylvania Department of Health 2002 Sample

Survey of the characteristics of the RN population reported

that the average age of nurses employed in the healthcare

field was 45.9. Of the total, 32.3 percent of the workforce

was between 50-64 years of age.

The aging of the nursing workforce needs to be viewed

in the context of a trend in the total population in the country

in all professions. People are living longer and healthier lives

and tend to remain in the workplace as long as possible. The

problem with nursing is that fewer younger nurses are

entering the workforce to replace retiring nurses, especially

in hospitals. There are also many more employment opportu-

nities in the wider healthcare field that offer higher wages,

opportunities for advancement and more acceptable working

hours.

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Table 4: Level of Education of Registered Nurse PopulationNursing Diploma Associate BSN MSN/ AdvancedPopulation 3 Years 2 Years Doctoral 5–7 Years

5–7 Years

HRSA Division of Nursing 22.3% 34.3% 32.7% 10.2%Nationwide Survey Sample,March 2000: PreliminaryFindings

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HRSA Profile, 40% 20% 30% 10%PA 1996

PA Department of Health 32.9% 30.1% 33.3% 11.3% 27%Nursing Survey2002

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June 2004 Page 9

adequacy, including enough RNs to provide high quality care

and adequate support services, and secondly, workforce

management. This second area included three issues:

administration listening and responding to nurses’ concerns,

the opportunity to participate in policy decisions and public

acknowledgments of the nurses’ contributions to patients. In

this survey nurse-physician relationships were not perceived

as highly problematic11.

Licensed Practical Nurses—

Selected Practical Nursing Workforce Issues: Many of

the issues identified for RNs also apply to LPNs. In addition,

there is a need for:

Increased LPN educational sites and student places (classroom

space).

Collegiate credit for courses taken as LPNs in LPN educational

programs.

Seamless entry from LPN educational programs into collegiate

RN programs.

There has been a significant decrease in the numbers of

LPNs employed in healthcare in Pennsylvania since the

above report for 1998. The Pennsylvania Department of

Health conducted a survey of LPNs in Pennsylvania in June

2002 at the time of license renewal. There were 48,233

license renewals. However, corrections for employment

status and other variables resulted in 33,578 LPNs reporting

employment in healthcare. Of these only 29,780 were

employed in Pennsylvania . Nursing homes provided

employment for 41 percent of LPNs employed in healthcare

and hospitals 24%.

The HRSA report identifies most recipients of LPN

degrees in Pennsylvania in 1997 as non-Hispanic white (85

percent) and female (92 percent). The Special Report on the

characteristics of the employed Licensed Practical Nurse

Population in Pennsylvania (June 2002)12 identifies the LPN

population as 91 percent white and 7.4 percent black.

Hispanics or other minorities are not identified.

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Retention and turnover of RNs in hospital settings:

The degree of the nursing shortage in hospitals is described

by the vacancy and turnover rate within a hospital. From a

study (2002) by the Hospital & Healthsystem Association of

Pennsylvania10, the following tables demonstrate the vacancy

and turnover rates for the regions of Pennsylvania between

the years of 2000 and 2001. The central and northeast

regions of the state, which include many of the rural

counties, had the greatest percentages of vacancies in their

nursing staff. Turnover rates were highest in the western part

of the state.

Note: Definition of vacancy and turnover and respective ratesare from: Pennsylvania Nurses: Meeting the Demand forNursing in the 21st Century (2001). The Hospital &

Healthsystem Association of Pennsylvania10.

According to the above report, high turnover rates for

nursing staff are problematic and, “lead to an increased use

of agency personnel, higher recruitment and retention costs

and increased orientation expenses; negatively impact staff

productivity and morale; and ultimately can hamper access

to delivery of patient care.”

Reasons for turnover vary, but in a survey conducted

on nurses working in hospitals in Pennsylvania by staff from

the University of Pennsylvania School of Nursing Center for

Health Outcomes and Policy Research, 41 percent of the

respondents reported dissatisfaction with their job and 22.7

percent were planning to leave their present job in the next

year. Discontent centered on two major areas: staffing

Table 5: Vacancy rates for RNs in PA hospitals(vacancy rate is defined as the % of budgeted positionsnot filled)

Year West Central and Southeast StateNortheast

2001 8.4% 14.4% 11.4% 11.1%

2000 7.5% 11.8% 11% 10%

Table 6: Turnover rates for RNs in PA hospitals(turnover rate is defined as the % of budgeted positionsleaving their job)


2001 13.6% 13% 12.6% 13.1%

2000 10.7% 9.4% 7.9% 9.1%

Table 7: Licensed Practical Nurses (LPNs)

LPNs 1998 PA Region III US PA Rank

Number 35,580 72,710 673,790 5/50

Number Employed 296.4 269.3 249.3 11/50Per 100,000

Ratio of LPNs 29 29.1 32 25/50to 100 RNs

Source: U.S. Department of Health and Human Services (DHHS),Health Services and Resources Administration (HRSA) StateHealth Workforce Profiles Report published in 2000.

Page 10 June 2004


Retention of LPNs in hospital settings: Turnover rates

in the more rural areas of the west decreased and remained

the same in the central and northeast regions.

Note: Definition of vacancy and turnover and respective ratesare from: Pennsylvania Nurses: Meeting the Demand forNursing in the 21st Century (2001). The Hospital &

Healthsystem Association of Pennsylvania.10

Table 8: Education Site of EmployedLPNs in PA, 2002

LPN Education Training Number Percent

Community college 3,083 10.5%Vocational tech schools 20,101 68.8%Hospital-based programs 3,317 11.4%Public school system 2,724 9.3%Total 29,225 100%

Source: Special Report on the Characteristics of the LicensedPractical Nurse population in Pennsylvania (2002). Pennsylva-

nia Department of Health.12

There are a total of 47 approved schools of practical

nursing in Pennsylvania, with 34 percent located in rural

counties. This has an effect on the high numbers of LPNs

working in rural counties. Between 1995 and 2002 the

number of LPN programs decreased by 10 at Vocational-

Technical schools. Since the highest percent of LPN

graduates working in Pennsylvania are from vo-tech schools,

these closures affect the numbers of available places for new

students. The total number of LPN graduates from all schools

in 2002 was 1, 236.12

Tables 8 and 9 demonstrate the following:

The LPN workforce in PA is also aging, with smaller numbers in

the 18-34 age group to replace those who retire.

The numbers indicate that Vocational-Technical Schools are the

site of choice (or convenient location) for LPN training. This is

important when developing recommendations for training sites

to increase the numbers of LPNs entering the nursing field.

Hospital based and public school system programs graduate

minimal numbers of LPNs.

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Table 9: LPN Education/Training by Site and AgeTraining Site Age 18–24 Age 35–49 Age 50–64 Age 65+

# % # % # % # %

Community 448 9.2% 1,655 12% 862 9.2% 52 8%College

Vocational 3,991 81.5% 9,944 71.9% 5,535 59.2% 311 47.8%Technical

Hospital- 167 3.4% 1,121 8.1% 1,744 18.7% 205 31.5%Based

Public Schools 290 5.9% 1,095 7.9% 1,208 12.9% 83 12.7%

Totals 4,896 13,825 9,349 651

Source: Special Report on the Characteristics of the Licensed Practical Nurse population in Pennsylvania (2002).Pennsylvania Department of Health. 12

Note: The survey didn’t identify whether or not the LPN educational sites had linkages with collegiate schools ofnursing to give college credit or have bridge courses to assist LPN graduates to continue with an RN-AD program.8.2% (2,429) of the respondents indicated that they are currently enrolled in an RN program.

Table 10: Vacancy rates for LPNs in PA hospitals(vacancy rate is defined as the % of budgeted positionsnot filled)


2001 5.5% 10.4% 11.1% 9.2%

2000 4.8% 10.2% 9.8% 8.6%

Table 11: Turnover rates for LPNs in PA hospitals(turnover rate is defined as the % of budgeted positionsleaving their job)


2001 10.7% 10.8% 9.8% 10.5%

2000 13.4% 10.7% 7.4% 10.1%


June 2004 Page 11

Table 13: Comparison of LPNs and RNsEmployment in Urban/Rural Counties

Employment Urban/ LPNs LPNs RNsRural Counties also RNs

Urban 72.9% 76.7% 85.2%Rural 27.1% 23.3% 14.8%

Source: “Comparison of responses to PA Department of Healthsurveys of registered nurses and licensed practical nursesemployed in healthcare in Pennsylvania”: April (RNs) and June

(LPNs) 2002, p.12

Nurse Practitioners (NPs; also called advanced practice

registered nurses or APRNs)—

APRN is an umbrella term given to a registered nurse

(RN) who has met advanced educational and clinical

practice requirements beyond the two to four years of basic

nursing education required of all RNs.

All advanced practice nurses must meet rigorous

educational, certification, and continuing education require-

ments. Standards of practice are set and monitored by

professional nursing organizations. Advanced practice nurses

work in collaboration with physicians and other health

professionals to coordinate health services for the patient.

Nurse Practitioner Practice: NPs and APRNs work in

clinics, nursing homes, hospitals, or their own offices. NPs

are qualified to handle a wide range of basic health prob-

lems. Most have a specialty, for example; adult, family, or

pediatric healthcare. NPs conduct physical exams, take

medical histories, diagnose and treat common acute minor

illnesses or injuries, order and interpret lab tests and X-rays,

and counsel and educate clients. As of this writing in 2003,

NPs may prescribe medication according to state law in 48

states. Many NPs work as independent practitioners and are

reimbursed by Medicare, Medicaid and private insurance for

services rendered.

Others work in administrative positions or clinical

practice for health maintenance organizations (HMOs), or

private industry. They provide pre-employment physicals for

employers, home healthcare to the elderly, health education

in hospitals, schools, and community clinics, geriatric care in

nursing homes, infectious disease control

in prisons, pre- and postnatal care in

inner city and rural clinics and psycho-

therapy in public and private practices.

Selected Nurse Practitioner Workforce Issues:

Barriers to practice including:

1. Limited access to patients due to legislative and regulatory

restrictions.

2. General lack of information about nurse practitioner education

and practice parameters by consumers and other healthcare

professionals.

3. HMO and other commercial health insurance policies that

exclude NPs as providers of care or limit reimbursement for

services provided.

4. Lack of support from the medical profession due to conflicting

views on parameters of practice for NPs.

Source: U.S. Department of Health and Human Services(DHHS), Health Services and Resources Administration(HRSA) State Health Workforce Profiles Report published in

2000.

Notes: Pennsylvania has one of the lowest ratios of nursepractitioners per capita population in the nation. This tabledoes not include nurse clinicians or nurse anesthetists whoalso come under the umbrella definition of advanced practice

registered nurses.

Nurse Midwives—

Midwifery practice, as conducted by CNMs and

CMs, is the independent management of women’s

healthcare, focusing particularly on pregnancy, childbirth,

and the postpartum period, care of the newborn and the

family planning and gynecological needs of women. The

Certified Nurse-Midwife and Certified Midwife practice

within a healthcare system that provides for consultation,

collaborative management or referral as indicated by the

health status of the client. Certified Nurse-Midwives and

Certified Midwives practice in accord with the Standards

for the Practice of Nurse-Midwifery, as defined by the

American College of Nurse-Midwives http://

www.midwife.org/

Table 12: LPN Employment InformationEmployed Nursing Hospitals Physician/ Home Other OtherLPNs Homes Dentists Health Health Sectors

41% 24% 13% 6.2% 8.2% 8.3%29,005 11,781 6,998 3,656 1,809 2,346 2,414

Source: Pennsylvania Department of Health Survey of LPNs 2002.

Table 14: Nurse Practitioners (NPs)

NPs 1998 PA Region III US PA Rank

Number 1,856 88,186(2000 HRSA Div.

of Nursing Survey)

Per 100,000 15.5 24.5 26.3 42/50

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Table 16: PA County Statistics for Nurse Midwives for 2001

Source: Extrapolated from Pennsylvania Department of Health Vital Statistics Report of2001 Pages 66 and 67.

Counties in PA Number Total Deliveries Total CNM In HospitalAll Providers Deliveries CNM

Rural 48 36,094 4,503 3,286Urban 19 107,310 8,074 6,632Totals 67 143,404 12,577 9,918

Counties in PA Out of Hospital % of Total % of Total % of AllCNM (Birth Ctr. Rural Urban Deliveriesand Home) Deliveries Deliveries

Rural 1,217 12.5%Urban 1,442 7.5%Totals 2,659 8.8%

Selected CNM Workforce Issues in Pennsylvania:

Lack of prescription writing privileges;

Lack of direct admitting privileges into hospitals for patients in

labor;

Lack of continuous representation on Board of Medicine (BOM).

Midwives in PA are licensed by BOM;

Exclusion from provider status with some commercial insurance

companies and managed care organizations;

Low reimbursement rates from some commercial insurance

companies and managed care organizations;

High malpractice insurance.

Source: National Sample Survey of Registered Nurses: HRSA,Bureau of Health Professions, Division of Nursing 2000 andU.S. Department of Health and Human Services (DHHS),Health Resources and Services Administration (HRSA) StateHealth Workforce Profiles Report 2000.

Comments:

Lancaster County, which had only 4.6 percent of Pennsylvania’stotal live births in 2001, accounted for 31.1 percent of all residentlive births in the state delivered outside of a hospital. (Author’snote: Midwife, 858; Physician 105; Other 42).Midwives delivered between 30- 45 percent of the births toresidents of eight counties: Clinton, Huntingdon, Juniata,

Lancaster, Mifflin Snyder, Somerset, and Warren.

In 2001 in Pennsylvania, 8.8 percent of all resident live births

were delivered by a midwife, compared to 2.8 percent in 1990

and 1.8 percent in 1980.

Dentistry:

The release of the first ever Surgeon General’s report

on Oral Health (2000) 14 has prompted many states and

organizations to evaluate the oral health of its residents. It

identified oral health as the nation’s “silent epidemic.”

Although Pennsylvania ranks high in number of dentists

compared to other states, there is a documented shortage of

oral healthcare professionals practicing in rural Pennsylva-

nia. The purpose of this section is to summarize the current

workforce issues in Pennsylvania and to identify potential

solutions.

A follow-up to the above report was released at the

2003 National Oral Health Conference in Milwaukee by U.S.

Surgeon General Richard Carmona. This Report, “The

National Call to Action”15 is the comprehensive national

strategy developed by a public-private partnership to address

the serious public health issues raised in the Surgeon

General’s report.

The Call to Action revolves

around a set of five principal actions

(see below) that describe the necessary

steps toward assuring that all Americans

achieve optimal oral health.

They include:

Changing perceptions of oral

healthcare.

Overcoming barriers to care using

proven models and programs.

Building the science base and

accelerating science transfer.

Increasing oral healthcare work

force diversity, capacity and flexibility.

Increasing collaboration.

The American Dental Hygienist

Association sates that, “Access to oral

health care is at the core of the National

Call to Action. The Surgeon General called upon healthcare

professionals to provide alternative models of delivery of

needed care for underserved populations, such as low-

income children or institutionalized persons.”16

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Table 15: Nurse Midwives

CNMs 2000 PA Region III US PA Rank

Number 231 9,232

ACNM Directory 3002001

Per 100,000 1.9 2.2 2.1 24/50

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June 2004 Page 13

In January 2004, the PA Department of Health

released a “Special Report on Characteristics of the Dentist

and Dental Hygienist Population in PA.”13 The dental section

of the Report was based on 6,800 dentists who responded to

a survey at the time of their license renewal.

Some of the findings from the respondents to this

survey included:

84.9% were in practice in PA.

Average age was 50.5 years.

15% anticipate leaving dentistry practice in five years or less.

93.3% engaged in direct patient care were white; 3.8% Asian;

1.5% black; and 1% Hispanic.

84.1% practiced in urban, and 15.9% in rural areas.

17.9% participate in the Medical Assistance program.

42% in the Children’s Health Insurance Program (CHIP).

Dental Workforce Issues:

The following section is excerpted from a presentation

by Dr. Neil Gardner, DDS, MPH on Dental Workforce Issues

in Pennsylvania, at the Pennsylvania Rural Health Confer-

ence, June 11, 2002.17

Trends in the dental workforce:

The number of dentists is declining nationally, while the demand

for dental services is increasing due to a variety of issues

including: a robust economy, aging baby boomers, and changes

in public program eligibility rules (Medicaid and CHIP), and

increased expectations of the population in relation to dental

health.

The federal capitation to dental schools from 1971 to 1981 to

address class size, socioeconomic disparities and distribution

problems, dramatically increased the numbers of dental school

graduates, resulting in a 52.4 % increase. This program ended

in 1981 due to a perception of oversupply and alumni pressure.

As of January 2002, there were 80 Dental Health Professional

Shortage Areas (DHPSA) designated in PA, involving nearly

1,421,669 people. Fifty seven are special population DHPSAs;

two additional DHPSAs involving another 56,000 are pending.

Increased numbers of dental hygienists with expanded responsi-

bilities will help to meet the needs.

There is a severe lack of utilization of dental services for children

under 21 who are eligible for Medicaid. Children in Pennsylvania

from the poorest families are three times more likely to have

untreated dental caries than children from the wealthiest

families.

The northwestern part of the state and the city of Philadelphia

have the highest disparity in access to dental services for

children in grade one needing immediate dental care.

Dental Hygienists—

As licensed oral health professionals, dental hygienists

focus on preventing and treating oral diseases—both to

protect teeth and gums—and also to protect patients’ total

health. Clinical dental hygienists work and/or volunteer in a

variety of healthcare settings that reach underserved popula-

tions, such as public health clinics, hospitals, schools,

managed care organizations and nursing homes, in addition

to private dental offices.

Goals of the Pennsylvania Dental Hygienist’s Associa-

tion18

Achieve autonomy of dental hygiene education, licensure and

practice.

Promote consumer advocacy in oral healthcare as part of total

health.

Serve as the recognized authority for the profession of dental

hygiene.

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Table 18: Dental Hygienists

Hygienists 1998 PA Region III US PA Rank

Number 5,750 12,990 140,750 43/50

Per Dentist 0.9 0.9 1.1 43/50

Per 100,000 47.9 48.1 52.1 37/50

Percent Female 99.1

Source: Bureau of Labor Statistics: American Dental Association;Bureau of the Census.

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Table 17: Dentists

Dentists PA Region III US PA Rank

Total Licensed 6,534 13,992 130,836 5/50

Per 100,000 54.4 51.6 48.4 11/50

Percent female 11.4 13% 12.6% 15/50

Percent female in 14.1PA 2003

13

Source: American Dental Association: Bureau of the Census.1 Special Report on Characteristics of the Dentist and DentalHygienist Population in PA. PA Department of Health, StateHealth Improvement Plan, January 2004.

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Page 14 June 2004


In January 2004, the PA Department of Health released

a “Special Report on Characteristics of the Dentist and

Dental Hygienist Population in PA.”13 the dental hygienist’s

section of the Report was based on 5,454 dental hygienists

who responded to a survey at the time of their license

renewal.

Some of the findings from the respondents to this

survey included:

91.5 percent were employed in dental hygiene.

Average age was 39.6 years.

98.2 percent were white; 0.8 black; and and 0.7 Hispanic.

99.3 were female.

91.7 percent were either “very satisfied or somewhat satisfied

with their career.

83.2 percent practice in urban and 16.8 in rural counties.

Dental Hygienists Issues:

The majority of the dental hygienist programs in Pennsylvania

are currently in the process of expanding so that they may

increase the number of graduates. Currently the number of

chairs is limited so the programs can accept only a limited

number of students.

The University of Pittsburgh is the only dental school in

Pennsylvania that has a dental hygienist program. The

University of Pennsylvania and Temple, both located in

Philadelphia, closed their programs in the mid 1980s.

Unfortunately, not all graduates stay to practice in PA. These

programs are very expensive to run and are the only allied

health programs that require their own clinical setting. Each

student must meet the accreditation standard’s number of

clinical hours for their education.

With the redefinition of rural counties and municipalities, none of

the dental hygienist schools are located in rural areas.

Licensure:

To qualify for licensure, a candidate must graduate

from an accredited dental hygiene school and pass both a

written and clinical examination. The American Dental

Association Joint Commission on National Dental Examina-

tions administers the written examination accepted by all

states and the District of Columbia. An associate degree is

sufficient for practice in a private dental office. A bachelor’s

or master’s degree usually is required for research, teaching,

or clinical practice in public or school health programs.

Employment:

Employment of dental hygienists is expected to grow

much faster than the average for all occupations through

2010. This is in response to increasing demand for dental

care and the greater substitution of the services of hygienists

for those previously performed by dentists. In the PA

Department of Health 2004 survey, dentists indicated that

they had difficulty finding dental hygienists to fill vacant

positions.

Dental Assistant—

Definition19: The dental assistant works chair-side with

the dentist, in the business office and in the dental laboratory.

Their duties include:

Instrument and infection control.

Prepare instrument trays.

Instruct patients on proper oral hygiene and post-treatment care.

Maintain practice records and supplies.

Process x-rays and schedule appointments.

Education:

Training and Other Qualifications—Most dental

assistants learn their skills on the job, though some are

trained in dental assistance programs offered by community

and junior colleges, trade schools, technical institutes, or the

Armed Forces.

Procedures a dental assistant may perform are

regulated on a state-by-state basis and may not include duties

assigned to dental hygienists.

In Pennsylvania a position of Expanded Functions

Dental Assistant is temporarily certified at this time.

Approximately 90 percent of the EFDAs holding temporary

certification have been trained on the job. The Pennsylvania

State Board of Dentistry does not require a certification

examination as yet.

Note: Only one Dental Assistant Training School is listed for

Pennsylvania in Hatboro (Montgomery County), Pennsylvania.

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Source: Bureau of Labor Statistics; American Dental Association;Bureau of the Census.

Note: There is a National Association of Dental Assistants, butPennsylvania does not have a separate state association.

Table 19: Dental Assistants

Dental Assistants PA Region III US PA Rank1998

Number 9,060 20,710 231,380 47/50

Per Dentist 1.4 1.5 1.8 47/50

Per 100,000 75.5 76.7 85.6 39/50

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June 2004 Page 15

Physician Assistants—

Physician Assistants are health professionals licensed

to practice medicine with physician supervision. Physician

Assistants (PAs) are qualified by graduation from an

accredited physician assistant educational program and/or

certified by the National Commission on Certification of

PAs. Within the physician/PA relationship, PAs exercise

autonomy in medical decision-making and provide a broad

range of diagnostic and therapeutic services. The clinical

role of PAs include primary and specialty care in medical

and surgical practice settings in rural and urban areas. PA

practice is centered on patient care and may include

educational, research and administrative activities. (Pennsyl-

vania Society of Physician Assistant’s website http://

www.pspa.net/)

Reimbursement:

Medicaid, Medicare, and many private insurers

recognize physician assistants. While physician assistant

certification within the Commonwealth represents “de-

facto” licensure as defined by the state attorney general’s

office, lack of licensure prevents reimbursement from some

private insurers for medical services provided by physician

assistants. With the passage of Act 160 in 2002, which

licenses physician assistants, negotiations are currently

underway to correct this restriction.

The data in Table 20 have been derived from several

sources: the American Academy of Physician Assistants 2001

census, the 17th Annual Report on Physician Assistant

Education; and information from the Health Resources and

Services Administration. Variations’ in reporting are directly

related to differing return rates on census administration and

statistical evaluation of the returns.

Ninety six percent of physician assistants in Pennsylva-

nia were non-Hispanic white, compared to 86 percent in the

general population and two percent were black/African

American compared to nine percent in the general population.

Practicing physician assistants have a wide distribution

in Pennsylvania, both rural, and urban:

49% of all respondents work in geographic regions with a

population of 50,000 or less.

25% work in geographic regions with a population less than

10,000.

26% declared the region in which they were employed was rural.

52% work in primary care specialties of family practice, general

internal medicine, emergency medicine, or general pediatrics.

AAPAs 2001 Annual Physician Assistant Census

Data, Pennsylvania:

The numbers in Table 21 below represent projected

distribution of providers based on the returns received. In

addition:

Mean Age of PAs is 38 years.

Current Academic Degree: 93% have a minimum of a bachelor’s

degree and 31% of respondents hold a masters degree.

In 2000, Pennsylvania had 14 Physician Assistant Educational

Programs with 364 graduates from 10 programs. Two of the

schools confer a bachelor’s degree and 14 offer a master’s

degree.

Source: American Academy of Physician Assistants, Bureau of theCensus.

Table 20: Physician Assistants 1999

Physician Assistants PA Region III US PA Rank

Number 1,597 3,365 28,443 4/50(2,991 registered

with PA Boardof Medicine in 2003)

Per 100Physicians 1998 5.3 5.1 4.9 28/50

Per 100,000 13.3 12.4 10.4 20/50

Percent Female 52.8

Percent Employed inInpatient HospitalSetting 32 28

Percent Employedin Ambulatory Setting 59 61

Table 21: (Table 2 in Report)Projected Distribution of Practicing PAs by State as of January 1, 2002

State # of PAs Practicing PA Population PAs Per Million Per Capita Per Capita Per Capita Per Capita Per Capitaas of 1/1/2002(a) (in 1,000s)(b) Population Ranking 2002 Ranking 2001 Ranking 2000 Ranking 1999 Ranking 1998

PA 2,425 12,281 197 18 18 20 23 20

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Future Job Security:

The United States Bureau of Labor Statistics (BLS)

projects that the number of Physician Assistant jobs will

increase by 53 percent between 2000 and 2010. The BLS

predicts the total number of jobs in the country will grow by

15 percent over this 10-year period.

Although there are no current or projected needs

identified for PAs practicing in rural (or urban) areas in

Pennsylvania the following information on PAs practicing in

the nation has been excerpted from The American Associa-

tion for Physician Assistants website. This information, in

addition to the data in above paragraphs, supports the wide

distribution of PAs practicing in rural areas of Pennsylvania.

PAs who are serving the needs of rural America

represent a significant percentage of the profession. In

addition to supporting the work of physicians who might

otherwise leave rural practice, in many cases PAs enable the

healthcare system to reach rural communities that cannot

support a physician. Rural PAs also impact the profession by

maintaining an important tie to one of its original tenets,

increasing access to primary care in underserved areas.

Further research would be required to identify what

factors influence PAs to choose rural practice. However, it is

likely that some of the reasons have to do with state practice

acts that allow maximum utilization of PAs, efforts to recruit

students from rural areas, improvements in the availability of

student financial aid through the National Health Service

Corps, and improvements in the National Rural Health Clinic

Services Act that have increased the number of rural health

clinics and the demand for rural PAs.

Note: References for this section are found in citation number

20.

Pharmacy—

Note: A member of the ADHOC Committee contacted the PAState Pharmacist Association but was unable to obtain informa-

tion specifically on Pennsylvania.

Pharmacists—

The following information from A Report to Congress

on the Pharmacist Workforce (DHHS, HRSA, Bureau of

Health Professions dated December 20, 2000), gives an

overview of the National Pharmacist Workforce Shortage

with a special section on practice in rural areas .21

General Information:

Pharmacists represent the third largest health professional

group in the U.S.

Evidence of the shortage is the demonstrably increased vacancy

rates, difficulties in hiring, and unprecedented increases in the

volume and range of activities demanded of today’s pharmacist.

The majority (slightly over 60%) of the nation’s pharmacists are

employed in the retail or community pharmacy sector and 29

percent are employed in institutional settings, principally

hospitals.

An important factor cited by this report is the fact that the

expanding role of the pharmacist increases as medications

become increasingly complex and diverse, and the potential for

their misuse grows. In addition to counseling patients on the

proper use of medication, the role of today’s pharmacist includes

drug monitoring, and disease management for defined

conditions; participating in multidisciplinary clinical care teams;

consulting on drug utilization programs; supporting health

services research on outcomes of care; providing drug

information; patient education; formulary management; and

furthering public health initiatives such as smoking cessation

programs, diabetes education and immunizations(p iii Executive

Summary).

Factors identified as contributing to the shortage:

Increased use of prescription medication.

Market growth and competition among retail pharmacies with

expanded store hours.

Increased access to healthcare and the increased number of

healthcare providers authorized to prescribe medications.

The double impact of increased insurance coverage for

prescription drugs, with increased volume and number of third

party payment issues.

Note: The majority of pharmacy graduates (79%) in PA in 1996-97were non-Hispanic white. Seventeen percent were Asian/PacificIslander and only 3% were black/African American, compared to3% and 9% of the general population, respectively.

Source: U.S. Department of Health and Human Services (DHHS),Health Services and Resources Administration (HRSA) StateHealth Workforce Profiles Report. 2000.

Table 22: Pharmacists

Pharmacists PA Region III US PA Rank1998

Number 8,210 18,640 178,110 8/50(196,000 stated

in the 2000 HRSAReport to Congress)

Per 100,000 68.4 69

Percent Female 49.1

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June 2004 Page 17

Consequences of Shortage:

Reduced time for pharmacist to provide patient counseling.

Job stress, inadequate working conditions, reduced professional

satisfaction.

Service restrictions particularly affect underserved or otherwise

vulnerable sectors of the population such as the elderly,

residents of rural communities, individuals with mental illness,

and persons dependent on publicly supported services such as

Native Americans and veterans.

Schools of Pharmacy in Pennsylvania:

There are six schools of pharmacy in Pennsylvania:

Temple University in Philadelphia, Duquesne Mylan School

of Pharmacy in Pittsburgh, Wilkes University School of

Pharmacy in Wilkes-Barre, University of Pittsburgh School

of Pharmacy, Lake Erie College of Osteopathic Medicine

School of Pharmacy and the Philadelphia College of

Pharmacy at the University of the Sciences in Philadelphia.

In 1998 these schools had a combined group of graduates

totaling 696 or 9.4 percent of the total in the nation.

There are 82 schools and colleges of pharmacy in the

United States. Applicants to these schools have been

decreasing over the past four years. There were a total of 7,

630 graduates in 2000. Estimates for future years (2006)

increase to 8, 054.

New Legislation that Expands the Role of Pharma-

cists in Pennsylvania:

Important legislation that enhances the practice of

pharmacy in Pennsylvania, was passed by the General

Assembly and signed by Governor Schweiker on June 29,

2002. The following excerpts are taken from the “ A

Pharmacist’s Guide to Act 102,” available on the

Pharmacist’s Association of Pennsylvania’s website http://

papharmacist.com. This legislation opens up new collabora-

tive relationships between pharmacists and physicians and

improves access to care for patients.

The major provisions of Act 102 (updating the

Pharmacy Act of 1961), affect primarily the “provision of

health care services” by pharmacists to patients, thereby

clarifying the role of the pharmacist in Pennsylvania as

healthcare providers. The new definition found in Act 102

replaces the previous language of providing prescriptions to

“consumers.”

The Act places enhanced emphasis on pharmacists as a

key component of a healthcare team involved in decision-

making, not just the supplier of a medication after the

decision has been made.

Any pharmacist in Pennsylvania may now also

administer medications by any route, regardless of practice

setting. The administration of injectable medications,

however, is limited to those pharmacists who meet the

requirements established for injectable drug administration.

Pharmacy Technicians—

The role of the pharmacy technician is to provide

technical and clerical support to pharmacists in hospitals or in

retail pharmacies. The pharmacy tech will measure, mix,

package, label and deliver drugs. Additionally, they maintain

computerized lists of medications taken by patients and

ensure that the right drugs have been prescribed. The

pharmacy technician will also look after home healthcare

products such as canes, vision aids and hearing aids. They

may also manage third party billing, answer telephones,

direct customers to items or the pharmacist for medication

consultation, receive written prescriptions, clean and sterilize

dispensing bottles and instruments, answer questions

regarding non-drug products, and operate a cash register.

Pharmacy Technicians are certified through the

Pharmacy Technician Certification Board., established in

1995. The only school for Pharmacy technician education

listed in Pennsylvania is the Duff’s Business Institute located

in Pittsburgh.

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Source: U.S. Department of Health and Human Services (DHHS),Health Services and Resources Administration (HRSA) StateHealth Workforce Profiles Report, 2000.

Pharmacy Technician Schools Website http://www.medical-training.info/pharmacyTechnician.html.

Table 23: Pharmacy Technicians and Aides 1998

Pharm. Techs PA Region III US PA Rankand Aides

Number 8,300 21,140 174,970 7/50

Per 100,000 69.2 78.3 64.7 17/50Per Pharmacist 1.01 1.13 0.98 24/50

Race/Ethnicity DegreeRecipients

White N/H 90%Black 8%Hispanic 1%Asian 2%

GenderFemale 81%Male 19%

Page 18 June 2004


Pharmacists In Rural Practice:

A white paper, titled “Implementing Effective Change

in Meeting the Demands of community Pharmacy Practice in

the United States, “ August 1999, co-written by the National

Association of Chain Drug Stores, American Pharmaceutical

Association, and the National Community Pharmacist

Association, emphasized the need for augmenting the

pharmacist’s resources through the appropriate use of

pharmacy technicians, and the enhanced use of technology

including: automation, robotics, and electronic transmission

of prescriptions.

The report includes a special section on Pharmacist

Supply and Practice in Rural Areas. (p.57) It states that two

studies show that pharmacists have a better distribution in

rural areas than other health professionals. The second study

showed that while the pharmacist’s presence in rural areas is

less than their average presence nationally, pharmacists have

a higher presence than primary care physicians, physician’s

assistants, nurse practitioners and nurse-midwives. Because

of this perception, (adequate supply), pharmacists are not

among the professionals included in the National Health

Services Corps Programs (see note below). This situation is

changing. Many communities are losing their pharmacists

with dire consequences because they may be the only

healthcare provider available.

Several factors distinguish rural pharmacy practice and

add to the problem of maintaining an adequate supply. These

include; remoteness, isolation from other professionals,

lower economic returns, and reduced opportunities for

advancement. Schools of pharmacy could play and important

role in encouraging more students to consider rural practice

by working with mentors and preceptors in rural communi-

ties.

Research addressing trends in the national rural supply

of pharmacists is scarce. Consolidation of pharmacies toward

larger population centers may decrease access for rural

residents.

Historically, rural areas have had a higher ratio of

independent pharmacies with a solo practitioner /owner. The

inability to secure a replacement upon retirement may result

in the loss of a pharmacy in a rural community. Ongoing

research to monitor trends in rural pharmacy practice will be

important to help ensure that rural communities retain an

adequate supply.

There were no specific recommendations in this report

to address the pharmacist shortage.

Note: Pharmacists will be included in a NHSC loan repaymentprogram in a demonstration project that began in 2003. Aminimum two-year service commitment is required, and theapplicant must be employed by a primary healthcare site thathas an active NHSC clinician on staff who is authorized toprescribe medications.

Awardees will be part of a three-year trial program that willinclude an evaluation to determine whether adding chiroprac-tors and pharmacists would enhance the effectiveness of the

NHSC.

Public Health—

Public health has been called a system of “organized

community efforts aimed at the prevention of disease and

promotion of health.” Its work is often described as three

core functions that fundamentally are public in nature:

assessing the health needs of a population, developing

policies to meet these needs, and assuring that services are

always available and organized to meet the challenges at the

individual and community levels. Though some aspects of

these core functions may be carried out by private-sector

professionals and organizations, ultimate responsibility and

accountability for them rests with government at the local,

state and federal levels. Public health activities are further

defined by the Ten Essential Public Health Services, which

expand upon the core functions and provide a more detailed

basis for defining the public health workforce.

Ultimately, a healthy population needs clean water and

air, safe food and housing, access to accurate information

regarding health and safety, and an adequate supply and

distribution of competent health professionals. These

conditions for health depend upon a strong public health

infrastructure, which includes a well-trained and accessible

public health workforce. This workforce is comprised of a

complex network of individuals from a variety of technical

backgrounds including nursing, health education, sanitation,

medicine and epidemiology, among others. The common

thread that ties these individuals to the public health

workforce is their commitment to addressing the health needs

of the population, as opposed to individual health needs.

Because of the loosely defined nature of the public

health workforce, it is difficult to determine exact numbers

of public health workers. Compounding the difficulties in

determining precise numbers is the fact that each state has

developed their public health infrastructure independently,

leading to dramatically different systems. Current best

estimates, however, place the number of public health

workers nationally at 448,254 persons, or 156 public health

workers per 100,000 population.


June 2004 Page 19

Pennsylvania ranks last among states, with only 37

public health workers per 100,000 population. This can

likely be traced to infrastructure development decisions

which have led to Pennsylvania having only 10 independent

health departments (all in urban areas). The remainder of the

state lacks a local public health infrastructure, and therefore

the entities through which additional public health workers

would be employed. It should be noted that this does not

necessarily mean that public health services are entirely

lacking in rural areas. Rather, hospitals, agricultural exten-

sion offices, voluntary organizations and others are likely

fulfilling a number of public health functions.

The challenge, however, is that public health services

provided by these entities are not uniformly provided across

communities and there is little coordination with state and

independent health departments. Without the necessary

public health infrastructure it is difficult to monitor these

efforts and assure that essential public health services are

being provided to all Pennsylvania’s citizens.

It should also be noted that Pennsylvania’s public

health infrastructure is unique among states in this region.

Surrounding states have all opted to create a locally based

system of public health agencies covering each county in

their state. As a result, per capita numbers of public health

workers are higher in each of these states (NJ 65/100,000;

OH 67/100,000; NY 73/100,000; WV 244/100,000; MD 304/

100,000). [Note that NJ has a local public health system

based at the township level rather than the county level.]

While causality is difficult to determine, Pennsylvania

faces a number of issues that may result from the low number

of public health workers. At the very least, it is safe to say

that a stronger public health infrastructure with an

adequate supply of public health workers will be a

critical component to addressing these issues, which

include the following:

Pennsylvania ranks second in the nation for overweight

and obesity.

Pennsylvania ranks third in the nation for number of

Super Fund sites.

Pennsylvania ranks seventh in the nation for low birth

weight infants.

Pennsylvania ranks seventh in the nation for number of

AIDS cases.

Pennsylvania ranks ninth in the nation for the number of

teen births.

Pennsylvania ranks in the top 90% among states for

carcinogenic and non-carcinogenic air and water releases.

Pennsylvania ranks in the bottom half of all states for high

rates of inadequacy of prenatal care, cancer cases, heart

disease, infant mortality and premature death, infectious

diseases, smoking, total mortality and violent crime.

The Pennsylvania Department of Health, Bureau

of Community Health Systems, through the six Medical

Districts, operates a network of six district offices, 57 health

centers, and acts as the implementation arm for the

Department’s public health programs.

Note: references for this section are found in citation number 22.

Essential Public Health ServicesMonitor health status to identify community health problems.

Diagnose and investigate health problems and health hazards in

the community.

Inform, educate, and empower people about health issues.

Mobilize community partnerships to identify and solve health

problems.

Develop policies and plans that support individual and community

health efforts.

Enforce laws and regulations that protect health and ensure

safety.

Link people to needed personal health services and assure the

provision of healthcare when otherwise unavailable.

Assure a competent public health and personal healthcare

workforce.

Evaluate effectiveness, accessibility, and quality of personal and

population-based health services.

Research for new insights and innovative solutions to health

problems.

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Page 20 June 2004


Mental Health—

There is a serious problem in maintaining a mental

healthcare workforce in Pennsylvania. This problem is

statewide but most provider shortage areas are in rural

counties.

Issues:

The information in this section is excerpted from the

following sources: A letter from James P. Gallagher, Admin-

istrator of the Luzerne-Wyoming Counties Mental Health/

Mental Retardation Program; the MH/MR Coalition

publication, “ Updates” of October 2002, January 2002; the

“MH/MR Coalition Budget Request for fiscal year 2003-

2003, 23 “ and the Legislative Budget and Finance

Committee’s Report in Response to House Resolution 450

(1999). 23, 24

The community MH/MR system is caring for persons

who are the state’s responsibility and is funded almost

entirely by state and federal resources. Increased funding is

needed each year to keep pace with the economy. Because of

inadequate or low cost of living increases over the past 15

years [specifically the Cost of Living Adjustments], wages in

the system are very low and often cannot compete with other

better paying employers, such as the fast food industry etc.

The MH/MR Coalition, a consortium of various state

associations representing providers and counties, strongly

advocates for additional funding to remedy the recruitment

and retention crisis. The Coalition identifies many factors

including; low salaries, a small pool of potential applicants,

lack of qualified workers, and less interest in the human

service fields. However, low wages are the key issue in high

turnover rates and difficulty in recruiting MH/MR staff.

The Coalition believes that recruitment and retention

of qualified staff to give high quality community based

services is jeopardized without adequate state and federal

funding. Since 1999, the Coalition has sent a budget request

to the Governor to give adequate funding for the recruitment

and retention of qualified workers.

The MH/MR Coalition was organized in 1999 to

promote the viability of the community mental health and

mental retardation workforce by meeting the following

objectives:I. Unify stakeholders based on common principles and objectives;II. Increase awareness of the workforce crisis in community mental

retardation and community mental health services and supportsamong policymakers;

III.. Promote adequate state funding to recruit and retain qualifieddirect support specialists;

IV. Recognize the connection between direct support specialists andquality of service;

V. Collect and analyze data relative to costs associated withproviding quality community services and supports;

VI. Secure funding to establish an apprenticeship program for directsupport specialists in community MH/MR programs.

Direct Care:

There are no state data on actual numbers of direct-

care mental health workers in Pennsylvania. In the HRSA

profile, DCWs are included in the data on nursing aides,

orderlies and attendants (70,860 in 1998). A high percentage

of direct care workers are minority; 35% are African

American and 10 percent Hispanic.

A survey of direct care workers (DCWs) employed in

mental health services in the Commonwealth in 1999 by the

Legislative Budget and Finance Committee24 (A joint

committee of the Pennsylvania General Assembly), indicated

that they earned an average of $8.13 per hour ($15, 854

annually), which was below the federal poverty level for a

family of four. Many (22%) earned less than $7 per hour.

The legislative report refers to their position as an

“entry level or journeyman level-providing direct care in a

residential or nonresidential mental health or mental

retardation program.” The position typically requires only a

high school or GED diploma.

Sources: U.S. Department of Health and Human Services(DHHS), Health Services and Resources Administration (HRSA)State Health Workforce Profiles Report, 2000 .

Bureau of Labor Statistics; American Medical Association; Bureauof the Census.

Note: The majority of psychologists and social workers in thenation in 1998 were non-Hispanic white, 84% and 65% respec-tively.

Table 24: Mental Health Providers in PA, 1998

MH Providers PA Region III US PA Rank

Psychiatrists # 1,524 3,633 29,937 4/50Per 100,000 12.7 13.5 11.1 11/50

Psychologists # 4,190 9,920 84,380 4/50Per 100,000 34.9 36.7 31.2 15/50

Social Workers # 39,750 71,830 583,770 3/50Per 100,000 331.2 266 216 5/50


June 2004 Page 21

Federal and State Funded Programs for Recruitment andRetention of Healthcare ProfessionalsFederal—

National Health Service Corps:

The National Health Service Corps supports doctors

and clinicians who serve in rural and inner-city areas that

lack adequate access to care. Nearly half of the program’s

clinicians currently serve in Community Health Centers,

which provide healthcare to people regardless of their ability

to pay and target services in areas where people face

financial and social barriers to accessing high-quality care.

NHSC Scholarship Program: A competitive scholarship program

designed for students committed to providing primary

healthcare in communities of greatest need upon completion of

their training. Benefits for up to four years of education include:

payment of tuition and fees, 12 monthly stipend payments per

year of scholarship support, and payment of other reasonable

educational expenses, such as books, supplies, and equipment.

To be eligible, the applicant must be a U.S. citizen enrolled, or

accepted for enrollment, in one of the following fully accredited

U.S. educational programs:

Allopathic or osteopathic medical schools

Family nurse practitioner programs (master’s degree in

nursing, post-master’s or post-baccalaureate

certificate)

Nurse-midwifery programs (master’s degree in

nursing, post-master’s or post-baccalaureate

certificate)

Physician assistant programs (certificate, associate,

baccalaureate, or master’s degree program)

Dental schools (This pilot program is open to only

third- and fourth-year students in selected schools.)

Source of information on NHSC Scholarships and loan

Repayment is taken from NHSC website http://

nhsc.bhpr.hrsa.gov/.

NHSC Loan Repayment Program (LRP): The purpose of the

NHSC LRP is to ensure an adequate supply of health profes-

sionals to provide primary health services to populations

located in selected health professional shortage areas

(HPSAs). The NHSC LRP assists clinicians in their repayment

of qualifying educational loans in return for service in HPSAs.

Applicants who are selected to participate agree to provide full-

time primary care services in an approved practice site located

in a federally designated health professional shortage area. For

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the two year minimum service commitment, the NHSC will pay

up to $50,000, based on the participant’s qualifying educational

loans, plus a 39 percent tax assistance payment. Opportunities

to continue participating in the program beyond two years may

be available. Eligibility for the NHSC LRP is open to fully trained:

Allopathic or osteopathic primary care physicians

Registered clinical dental hygienists

Primary care certified nurse practitioners

Primary care physician assistants

Certified nurse-midwives

General practice dentists

Clinical or counseling psychologists

Clinical social workers

Licensed professional counselors

Marriage and family therapists

Psychiatric nurse specialist

Nurse Reinvestment Act of 2002:

In response to the national nursing shortage, the Nurse

Reinvestment Act of 2002 was signed into law in August

2002. The Act amends Title VIII of the Public Health Service

Act: Nursing Workforce Development (the primary authoriza-

tion of existing federal nursing programs) and authorizes new

programs to increase the number of qualified nurses and the

quality of nursing services in the U.S. Funding to implement

the new programs was appropriated by Congress in February

2003. Source: http://bhpr.hrsa.gov/grants/default.htm. Note

that funding for any level depends on the yearly federal

budget for the Division of Nursing. The above website gives

summaries of available funds for specific grant programs for

current fiscal year (2004.)

There are six levels of the Nurse Reinvestment act:

Nursing Scholarship: In exchange for at least two years service

at a healthcare facility with a critical shortage of nurses, nursing

scholarships pay tuition, required fees, other reasonable costs,

including required books, clinical supplies, laboratory expenses,

etc. and a monthly stipend ($1,098 for the 2003-2004 academic

year). U.S. citizens or nationals enrolled or accepted for

enrollment as a full-time or part-time student in an accredited

school of nursing in a professional program (baccalaureate,

graduate, associate degree, or diploma) are eligible to apply.

Qualified applicants who have the greatest financial need receive

funding preference.

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Building Career Ladders: to enhance the nursing workforce byinitiating and maintaining nurse retention programs that promote

career advancement for nursing personnel in a variety of trainingsettings, cross-training or specialty training among diversepopulation groups, and the advancement of individuals tobecome professional nurses, advanced practice nurses,advanced education nurses, licensed practical nurses, certifiednurse assistants, and home health aides, and assist individuals

in obtaining education and training required to enter the nursingprofession and advance within such profession, such as byproviding career counseling and mentoring.

Schools of nursing, healthcare facilities, or a partnership of sucha school and facility, nursing centers, academic health centers,state or local governments, other public or private nonprofit

entities are eligible to apply.

Internship and Residency Programs: to develop and implementinternship and residency programs for nurse graduates andregistered nurses (RNs) to improve education and nursingpractice in the workplace, the quality of care, and the retention ofRNs in the workforce.

Schools of nursing, healthcare facilities, a partnership of such aschool and facility, nursing centers, academic health centers,state or local governments, other public and private nonprofitentities, including faith-based and community-based organiza-tions, are eligible to apply.

Enhancing Patient Care Delivery Systems/Nurse Retention: to

improve the retention of nurses and enhance patient care that isdirectly related to nursing activities by enhancing collaborationand communication among nurses and other healthcareprofessionals and promoting nurse involvement in the organiza-tional and clinical decision-making processes of a healthcarefacility.

Schools of nursing, nursing centers, academic health centers, ahealthcare facility, or a partnership of such a school and facility,state or local governments and other public or private nonprofitentities are eligible to apply.

Comprehensive Geriatric Education: designed to train andeducate individuals in providing geriatric care for the elderly: FY

2003 focus is on projects that enhance the knowledge, skills,and leadership potential of registered nurses (RNs) providingcare to older adults in a variety of settings. Projects mustdemonstrate that the preparation of RNs benefits licensedpractical nurses and certified nurse assistants.Schools of nursing, healthcare facilities, programs leading to

certification as a certified nurse assistant, partnerships of aschool and a healthcare facility and partnerships of a program

leading to CNA certification of a healthcare facility are eligible toapply.

Nurse Faculty Loans: No information posted on web site as yet.

Nursing Education Loan Repayment Program:

The Nursing Education Loan Repayment Program

(NELRP) offers registered nurses substantial assistance to

repay educational loans in exchange for service in critical

shortage facilities. Authorized by Section 846 of the Public

Health Service Act, as amended, the purpose of the NELRP

is to assist in the recruitment and retention of professional

nurses dedicated to providing healthcare to underserved

populations. Applicants must meet the following eligibility

requirements by the FY 2004 application due date, midnight

ET February 25, 2004:

Be a registered nurse (RN).

Have received a baccalaureate or associate degree in nursing

(or an equivalent degree), a diploma in nursing or a graduate

degree in nursing from an accredited school of nursing.

Have unpaid qualifying loans obtained for nursing education

leading to a degree or diploma in nursing.

Have completed the nursing education program for which the

loan balance applies.

Be a citizen, national or permanent legal resident of the United

States.

Be employed full time (32 hours or more per week) at a critical

shortage facility.

Have a current permanent unrestricted license as an RN in the

State in which they intend to practice or be authorized to

practice in that State pursuant to a Nurse Licensure Compact.

Submit a complete FY 2004 NELRP application, signed NELRP

contract and all required.

All NELRP participants must enter into a contract

agreeing to work full time in an approved critical shortage

facility. For two years of service, the NELRP will pay 60

percent of the participant’s total qualifying loan balance. A

participant who agrees to serve two years may be eligible to

amend the NELRP contract and work a third year at a critical

shortage facility, for which the NELRP will pay an additional

25 percent of the qualifying loan balance.

Nurse Shortage Counties in Pennsylvania are: Beaver,

Carbon, Clinton, Crawford, Delaware, Elk, Franklin, Fulton,

Huntingdon, Lebanon, McKean, Mifflin, Northumberland,

Potter, Schuylkill, Susquehanna, Tioga, Venango, and

Wayne.

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June 2004 Page 23

Federal/State: The Pennsylvania Department of

Health Loan Repayment Program:

Section 3381 of the (federal) Public Health Service

Act authorizes the Secretary to make grants to States to

assist in the repayment of educational loans to health

professionals who agree to provide primary healthcare

services in federally designated health professional shortage

areas (HPSAs). In return, health professionals practice in

HPSAs for a required period of years..

In Pennsylvania this loan repayment program is

located in the Department of Health, Bureau of Health

Planning and supported through both Federal National

Health Service Corps and state funds. It is authorized under

Act 113 of 1992 (Children’s Health Care Act), Chapter 13.

The goal of the program is to encourage primary care

practitioners (including dentists) to practice in a Health

Professional Shortage Area (HPSA) in Pennsylvania.

Administered jointly with the Pennsylvania Higher Educa-

tion Assistance Agency, it provides payments of educational

loan obligations based on the length of time the practitioner

practices in the HPSA. Payments increase based upon the

length of practice in the area. Awards are made of up to

$64,000 for physicians and dentists and up to $40,000 for

certified registered nurse practitioners, physician assistants

and certified nurse midwives. Since the Program’s inception

in 1992, there have been over 200 participants.

Disciplines and specialties eligible:

Physicians must be board eligible/board certified and practicing

in the following primary care specialties: Family Practice,

Internal Medicine (General), Pediatrics, Obstetrics/Gynecology

Osteopathic Physicians: General Practice (at least two years

postgraduate training)

General Dentists

Certified Registered Nurse Practitioners (CRNPs) practicing in

the above primary care specialties

Physician Assistants (PA-C) practicing in the above primary

care specialties

Certified Nurse Midwives (CNM)

Ob/Gyn practitioners must provide prenatal care and obstetric

services. Practitioners who practice only gynecology are not

eligible to participate in the LRP.

To apply for the LRP in Pennsylvania, each practitio-

ner must be a citizen of the United States who:

Has a degree in allopathic or osteopathic medicine, or other

health profession, or is certified/licensed as a nurse midwife,

certified registered nurse practitioner, or physician assistant.

Has a valid unrestricted Pennsylvania license/certificate to

practice the healthcare profession for which the individual is

applying to the program.

Be enrolled in his/her final year in an approved residency

program in allopathic or osteopathic medicine or, has completed

an approved residency program in allopathic or osteopathic

medicine.

Is enrolled in his/her final year of an approved educational

program leading to certification and licensure as a Certified

Registered Nurse Practitioner, a Nurse Midwife, or Physician

Assistant.

Has submitted a complete application to participate in the LRP.

LRP participants must be employed continuously in a

full-time (40 hours per week) primary care practice at an

approved location.

State—

Pennsylvania Nursing Loan Forgiveness for

Healthier Futures:

To help recruit and retain qualified nursing students in

Pennsylvania, the “Nursing Loan Forgiveness for Healthier

Futures” helps to repay student loans. By working for a

participating Pennsylvania healthcare organization, after

graduation from an approved nursing education program, a

nurse may receive student loan forgiveness for up to 25

percent (a maximum of $12,500) of an eligible debt over a

three-year period. At a minimum, participating employers

will match our loan forgiveness contribution; however,

employer-sponsored programs will have the added flexibility

to increase their matching contribution to enhance their

organization’s nurse recruitment and retention efforts.

Source: http://www.pheaa.org/loanforgiveness/

healthier_futures_guidelines.shtml.

To qualify, a nurse must:

Have outstanding AES/PHEAA owned, guaranteed, and serviced

federal Stafford loans in good standing.

Must have graduated from a licensed nursing program in

Pennsylvania or have been a Pennsylvania resident at the time

of application for Stafford loans.

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Complete a qualifying program of study, no earlier than 2004,

leading to a Certificate/Diploma/ Degree as a Licensed Practical

Nurse within Pennsylvania, Registered Nurse within Pennsylva-

nia, or Nurse Educator within Pennsylvania.

Pass the Pennsylvania licensure examination for a license to

work as a Practical Nurse or Registered Nurse within nine

months of receiving the nursing degree

Begin full-time employment: within three months of graduation

as a direct patient care nurse at an approved, participating

Pennsylvania facility, or within one year of graduation, as a

nurse educator in an approved, participating Pennsylvania post-

secondary education program.

Complete at least one full year of continuous, full-time, direct-

care employment or employment as a nurse educator at

participating employer’s Pennsylvania qualified facility.

Have the participating employer verify the completion of

continuous, qualifying employment throughout the year.

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June 2004 Page 25

Other Initiatives Aimed at Improving the HealthcareWorkforce in PennsylvaniaThe Hospital & Healthsystem Association ofPennsylvania

This association has been foremost in the state in its

extensive and continuous work with workforce issues and

comprehensive up-to-date reports on problems relating to the

healthcare workforce with recommended solutions.

HAP efforts on healthcare workforce include:

Advancing an advocacy agenda.

Developing tools, information, and education for hospitals and

health systems to aid in retention and recruitment.

Fostering collaboration on healthcare career opportunities,

outreach, and care design.

Enhancing public awareness of healthcare.

Worker supply

As part of these multiple efforts, the HAP website

(http://haponline.org) contains a “Workforce” section with

up-to-date information and publications to gain attention of

policymakers and to assist consumers of health and provid-

ers of care to deal with health workforce issues, including:

Recruitment and retention practices

State Board of Nursing information

Workforce career outreach information

Workforce studies, reports, and information

Colleagues in Caring information

Association studies and reports

Other state association reports

Other Professional Reports & Government Studies

Workforce Resources

Workforce Testimony

Links

Magnet Hospitals

These are model hospitals that have successfully

attracted and retained professional nurses (see website for

eligibility and benefits26). As of 2004, five Pennsylvania

hospitals: Lehigh Valley Hospital & Health Network,

Allentown; Lancaster General Hospital, Lancaster; Abington

Memorial Hospital, Abington; Children’s Hospital of

Philadelphia; and Fox Chase Cancer Center, Philadelphia;

have been awarded Magnet designation by the American

Nurses’ Credentialing Center.

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The Magnet Recognition Program for Excellence in

Nursing Service awards important national recognition to

healthcare organizations that demonstrate sustained excel-

lence in nursing care. The prestigious program is adminis-

tered by the American Nurses Credentialing Center, the

nation’s largest and foremost nursing accrediting and

credentialing organization.

The objectives of this program are:

To recognize nursing services that utilize the scope and

standards for nurse administrators to build programs of nursing

excellence in the delivery of nursing care to patients.

To promote quality in a milieu that supports professional nursing

practice.

To provide a vehicle for the dissemination of successful nursing

practices and strategies among institutions utilizing the services

of registered professional nurses.

Ongoing Data Collection

The Pennsylvania Department of Health—

The following paragraph is taken from the Introduction

to the PA Department of Health’s “Special Report on the

Characteristics of the Licensed Practical Nurse Population in

Pennsylvania.” 12

In response to legislative concerns about the lack of

objective information to focus the policy discussion concern-

ing the shortage of health professionals, the Department of

Health convened a Health Professions Study Group (January

2002) comprised of academics, policy leaders, nursing

association leaders, hospital and long term care association

representatives and other interested stakeholders which is

working to identify strategies to assure that an adequate and

appropriately distributed supply of health professionals will

be available to meet the needs of Pennsylvania’s diverse

population.

In addition, the health professions study group has

published the following reports:

“Special Report on the Characteristics of the Registered Nurse

Population in Pennsylvania,” November 2003 and June 2003

“Special Report on the characteristics of the Licensed Practical

Nurse Population in Pennsylvania,” June 2002

“Report on the Status of Nursing Education Programs in

Pennsylvania,” April 2003

“Special Report on the Characteristics of the Dentist and Dental

Hygienist Population in Pennsylvania,” January 2004

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The Pennsylvania Office of Rural Health

(PORH)—

Has been awarded a grant from the Center for Rural

Pennsylvania to conduct a supply and demand analysis of

dental services provided to indigent populations in Pennsyl-

vania.

Federal Workforce Investment Act of 1998

Information in this section excerpted from the

following sources: two publications of The Hospital &

Healthsystem Association of Pennsylvania: “Understanding

Pennsylvania Workforce Investment Opportunities: Tools for

Health Care Leaders in Workforce Planning and Develop-

ment”27 and “Building a Connection between the Workforce

Investment System and Health Care,”28 and the Pennsylvania

WIB Implementation website at http://

www.paworkforce.state.pa.us/pa_workforce/site/default.asp.

Public Law 105-220 signed by President Clinton on

August 7, 1998 called for the creation of a national network

of statewide, locally driven workforce investment systems to

increase the employment, productivity, occupational skill

attainment, and competitiveness of national, state, and local

economies through consolidation, coordination and continu-

ous improvement.

WIA Title I - authorizes a new workforce investment

system.

WIA Title II - reauthorizes adult education and literacy

programs for fiscal years 1999-2003

WIA Title III - amends the Wagner-Peyser Act to

require that employment service/job statistics become part of

the “One-Stop” system and establishes a national employ-

ment statistics initiative.

The Workforce Investment Board provides the

framework for a unique national workforce preparation and

employment system designed to meet both the needs of the

nation’s businesses and the needs of job seekers and those

who want to further their careers. Title I of the legislation is

based on the following elements:

Training and employment programs must be designed and

managed at the local level where the needs of businesses and

individuals are best understood.

Customers must be able to conveniently access the employ-

ment, education, training and information services they need at

a single location in their neighborhoods.

Customers should have choices in deciding the training program

that best fits their needs and the organizations that will provide

that service. They should have control over their own career

development.

Customers have a right to information about how well training

providers succeed in preparing people for jobs. Training

providers will provide information on their success rates.

Under Title 1 of this Act, Pennsylvania has Work

Investments Boards in 22 areas. These 22 local WIBs are

responsible for carrying the responsibilities outlined for local

boards under the WIA.

The Hospital & Healthsystem Association of Pennsyl-

vania, in cooperation with the Pennsylvania Workforce

Investment Board, has developed a publication called “A

Guidebook Building a Connection between the Workforce

Investment System and Health Care, “to acquaint local

workforce investment board members and Team Pennsylva-

nia CareerLink staff with ways Pennsylvania’s hospitals and

health systems are learning about Pennsylvania’s workforce

development system and are determining how a relationship

with, and involvement, in the local WIB, youth council and

Team Pennsylvania CareerLink centers might serve to

address hospital and health system workforce development

requirements.”

Examples include:

Working with local WIBs and youth councils to devote resources

to develop a strategy linked to workforce development in

healthcare.

Becoming involved in community planning processes.

Learning about Team Pennsylvania CareerLink resources and

how those resources can serve to assist healthcare organiza-

tions to fill vacant positions and enhance current employee

skills.

Looking for opportunities to leverage organizational resources to

establish or enhance workforce development programs under

consideration or in existence by one or several other healthcare

organizations.

Working in collaboration with education organizations and other

Team Pennsylvania CareerLink partners to build seamless

education pathways for a particular health career.

An excellent example of working together with the

WIB is the Critical Jobs Training Grant Nurse Workforce

Project: The Philadelphia Workforce Investment Board,

Philadelphia Workforce Development Corporation, and

Delaware Valley Healthcare Council of The Hospital &

Healthsystem Association of Pennsylvania partnered to

develop a proposal under the state’s Critical Jobs Training

Grant program to address the most critical workforce need

identified in its studies, the shortage of nurses. The proposal

builds on the region’s life sciences initiative to build a

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June 2004 Page 27

continuum of career movement,

addresses the need for diversity in the

workforce, and builds on the collabora-

tive model of the broader life sciences

effort. The proposal includes:

Nurse aide training.

Licensed practical nurse training.

Training persons with bachelor’s or

master’s degrees to complete registered

nurse requirements in only 11 months.

Facilitating licensing of graduate Latino

nurses.

New nurse graduate mentoring to

increase retention of critically needed

staff nurses.

The state awarded $700,000 to

carry out the first three parts of the

proposal and train 114 workers.

Training partners for the project include Community College

of Philadelphia, Episcopal School of Nursing, Bucks County

Community College and Drexel University. Proposals for the

additional parts of the project not covered by the grant are

being submitted for funding.

The Pennsylvania Critical Job TrainingGrants Program

Note: At present a moratorium has been placed on the

critical job training grant program. This information has

been included as an example of how the problem of short-

ages of healthcare providers has been addressed at a county

level with state funds. Research is needed on the success of

this program and the number of healthcare providers trained.

Information on the Critical Job Training Program has

been taken from the following website https://

www.esa.dced.state.pa.us/SingleApp.nsf/Homecjtg.

This program was not specifically for training

healthcare workers. However, community groups in the six

counties listed at the end of this section took advantage of

the funds available in 2002 for this purpose.

Pennsylvania Center for Health Careers

The Center for Health Careers will be housed,

coordinated and staffed by the Pennsylvania Workforce

Investment Board (PA WIB) and will provide a coordinated

plan and focused leadership to address future demands;

target career outreach; and provide financial assistance to

students and educational programs,”

The Center will be a private/public Industry Partner-

ship and will serve as a catalyst to develop action-oriented

strategies to address Pennsylvania’s short- and long-term

health-care workforce challenges. In its first year, the Center

seeks to address four key challenges:

Increasing educational capacity.

Creating career ladders in healthcare.

Helping employers retain healthcare workers.

Establishing a regional direct care workforce center pilot project.

Source: Excerpts from Governor Edward Rendell’s Press

Release., April 12, 2004

Other

Additional sources of information for workforce

development programs in Pennsylvania is The Department of

Community and Economic Development (DCED) website.

Information is available on Customized Job Training,

Guaranteed Free Training Program, and the Workforce

Leadership Grants Program. The implementation and

continuance of any of the programs depends on funding

through yearly budgets.

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Received Critical Job Training Grants

County Amount of Grant Training Program

Blair $475,000 150 certified nursing assistants and 75 licensed practicalnurses.

Butler 225,000 150 healthcare workers for positions in Indiana County,concentrating on companions, certified nurse assistants,licensed practical nurses, registered nurses, and healthtechnicians.

Cambria 226,594 100 individuals, focusing on gerontological nurse’s aidesand licensed practical nurses, and a refresher course fornurses.

Luzerne 320,000 19 licensed practical nurses, 18 certified nursing aids,and eight medical technicians.

Montgomery 75,000 60 certified nurse assistants from the North Philadelphiaregion.

Philadelphia 155,250 75 dislocated workers in mental health/mentalretardation, substance abuse and long-term careservices

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June 2004 Page 29

References

Citations

1 Pennsylvania Department of Health, Bureau of Health

Statistics and Research “Directory of Pennsylvania

Hospitals and Ambulatory Surgery Centers 2002”.

2 Pennsylvania Department of Health, Bureau of Health

Statistics and Research “Directory of Pennsylvania

Nursing Homes 2002.”

3 Pennsylvania Office of Rural Health in Cooperation with

Pennsylvania Area Health Education Center Program.

“Community Health Centers and Other Affiliated Clinical

Sites in Pennsylvania 1997”

4 U.S. Department of Health and Human Services (DHHS),

Health Services and Resources Administration (HRSA).

“State Health Workforce Profiles: Pennsylvania”. 2000.

5 Pennsylvania State Board of Nursing, “Professional

Nursing Law.” website is accessed through the Depart-

ment of State, Bureau of Professional Affairs website

http://www.dos.state.pa.us/bpoa/

6 Department of Health and Human Services, Health

Resources and Services Administration, Division of

Nursing, “The Registered Nurse Population National

Sample Survey of Registered Nurses,” March 2000

Preliminary Findings, February 2001.

7 Pennsylvania Department of Health. “Special Report on

the Characteristics of the Registered Nurse Population in

Pennsylvania”. Combined data from the survey of

Registered Nurses renewing licenses in April and October

2002.

8 Pennsylvania Department of Health. “Report on the

Status of Nursing Education Programs in Pennsylvania”.

2003.

9 The Hospital & Health System Association of Pennsylva-

nia, “Pennsylvania Nurses: Meeting the Demand for

Nursing in the 21st Century, 2001”.

10 The Hospital & Health System Association of Pennsylva-

nia, “Pennsylvania Nurses: Meeting the Demand for

Nursing in the 21st Century, 2002 Update”

11 Linda H. Aiken, P. Clarke, et al. “Nurses Reports On

Hospital Care in Five Countries, “ Health Affairs, ,

Volume 20, Number 3, May/June 2001. (This report

focuses on findings from a survey of nurses working in

711 hospitals in five countries, including 13, 471 nurses

working in adult acute care hospitals in Pennsylvania.)


the Characteristics of the Licensed Practical Nurse

Population in Pennsylvania”. 2003.


the Characteristis of Dentists and Dental Hygienists

Population in Pennsylvania”. 2003.

14 A Report of the Surgeon General David Satcher., “Oral

Health in America”. May 25, 2000.

http://www.surgeongeneral.gov/library/reports.htm.

15 A Report of the Surgeon General Richard Carmona. “A

National Call to Action to Promote Oral Health”. May

2003.

16 American Dental Hygienist Association Press Release.

“Access to Oral Health Care”. May, 7, 2003.

17 Neil Gardner DDS, MPH. “National and PA Dental

Manpower Issues: Explanations, Interpretations and

Suggested Solutions”.: Presentation at Rural Health

Conference, State College, PA, June, 2002.

18 Personal communication from Peggy Yurcho, President

Pennsylvania Dental Hygienists Association, March 17,

2004

19 American Dental Assistants Association (ADAA) website

http://www.dentalassistant.org/.

20 References for Section II, Number 3. Physician Assistant

Section

1) Willis JB. Is the PA Supply in Rural American Dwin-

dling? J Am Acad Phys Asst; 1990;3:433-5.

2) American Academy of Physician Assistants. 2001

AAPA Physician Assistant Census Report. October 6,

2001.

Page 30 June 2004


3).American Academy of Physician Assistants. Testimony

of the American Academy of Physician Assistants to the

Physician Payment Review Commission. November 29,

1993.

4) American Academy of Physician Assistants. Testimony

of the American Academy of Physician Assistants to the

Physician Payment Review commission. November 29,

1993.

5) Health Care Financing Administration, US Department

of Health and Human Services, Federally Certified Rural

Health Clinics by State. Unpublished data. September

1995.

21 Department of Health and Human Services, Health

Resources and Services Administration, Bureau of Health

Professions, “ The Pharmacist Workforce: A Study of the

Supply and Demand for Pharmacist,” December 2000.

22 References for Section II, Number 5: Public Health in

Pennsylvania

1) Bureau of Health Professions, National Center for

Health Workforce Information and Analysis, The Public

Health Work Force Enumeration 2000. U.S. Health

Resources and Services Administration, December 2000.

2) Bureau of Health Statistics and Research, Pennsylvania

Department of Health, “Maternal and Child Health Status

Indicators,” www.health.state.pa.us/stats/.

3) Environmental Defense Scorecard, http://

www.scorecard.org/.

4) Institute of Medicine, The Future of Public Health,

National Academy Press: Washington, DC, 1988.

5) Kaiser Family Foundation State Health Facts Online:

50 State Comparison, http://www.statehealthfacts.kff.org.

6) Pennsylvania Department of Health, “2000 Behavioral

Health Risks of Pennsylvania Adults,” http://

www.health.state.pa.us/health/lib/health/

tobacco_use_brfss_2000.pdf and http://

www.health.state.pa.us/health/lib/health/

overweight_brfss_2000.pdf.

7) Pennsylvania Department of Health, Health Status

Indicators, “Health Status Indicators by Department of

Health District, 1998-2000, http://www.health.state.pa.us/

health/lib/health/dist_sum2002.pdf.

8) Public Health in Pennsylvania: Critical Issues for

Challenging Times, An Issue Paper from the Deans of the

Commonwealth’s Schools of Public Health, http://

www.cphp.pitt.edu/criticalissues.pdf.

23 Personal Communication. James P. Gallagher, Adminis-

trator, Luzerne-Wyoming Counties Mental Health/Mental

Retardation Programs, January 2003, and MH/MR

Coalition Newsletters, May 7, 2001, October 25, 2002,

January 13, 2003.

24 Pennsylvania General Assembly Legislative Budget and

Finance Committee, “ Salary Levels and Their Impact on

Quality of Care for Client Contact Workers in Community

Based Mental Health/Mental Retardation Programs”: A

response to House Resolution 450, February 1999.”

25 The Hospital & Healthsystem Association of Pennsylva-

nia, Health Care Workforce Toolkit, Memo 02-49, to

Chief Executive Officers of HAP Member Hospitals and

Health Systems, from Carolyn F. Scanlan, President and

CEO.

26 American Nurses Credentialing Center website: http://

nursingworld.org/ancc/.


nia, “Understanding Pennsylvania Workforce Investment

Opportunities: Tools for Health Care Leaders in

Workforce Planning and Development”. 2002.


nia, “Building a Connection Between the Workforce

Investment System and Health Care”. 2002.”


June 2004 Page 31

References

Appendix A

Selected characteristics of the population of Pennsylvania .................................................................................................. 32

Source: U.S. Department of Health and Human Services Health Services and Resources Administration

State Health Workforce Profiles Report , 2000

“State Health Workforce Profiles: Highlights, Pennsylvania ............................................................................................... 33

Source: Department of Health and Human Services, (DHHS), Health Resources and Services

Administration (HRSA), 2000

Definition of rural/urban Census 2000 ................................................................................................................................. 34

Source: The Center For Rural Pennsylvania

Comparison of responses of Pennsylvania “Survey of RNs with license renewal due April, 2002", to

Pennsylvania “Survey of LPNs with license renewal due June 2002"; selected demographics and

employment information ................................................................................................................................................ 35–36

Source: Pennsylvania Department of Health

Comparison of responses of national sample survey of registered nurses, March 2000, to Pennsylvania

RN licensure survey on selected demographics and employment information .............................................................. 37–38


The Workforce Strategy Map ............................................................................................................................................... 39

Source: In Our hands: How Hospital Leaders Can Build a Thriving Workforce AHA Commission on

Workforce for Hospitals and Health Systems, 2003

Definitions of practice and information on the educational programs for selected healthcare providers:

RNs, LPNs, Nurse Practitioners, Nurse Midwives, Dental Hygienists, Dental Assistants and Physician Assistants ..... 40–43

Page 32 June 2004


References

Appendix A


June 2004 Page 33

References

Appendix A

State Health Workforce Profiles: Highlights, Pennsylvania.

Source: Department of Health and Human Services, (DHHS),

Health Resources and Services Administration (HRSA). December 2000

Highlights

By 2020, the total population of Pennsylvania is projected to grow 3%, and the population over 65 is projected to grow 24%,

compared to national growth projections of 18% and 53%, respectively. (In effect, population growth in Pennsylvania will be 1/

6th of the national rate, while our senior population growth will roughly be ½ the national growth.) (DHHS, HRSA 2000)

In 1998, ten percent of Pennsylvania’s total workforce, or 580,000 persons, were employed in the health sector. This is in

contrast to nine percent of the total U.S. labor force. Approximately forty seven percent of health service workers were

employed in hospitals, 20% in nursing and personal care facilities and 4.5% in home healthcare..

Blacks/African Americans and Hispanics are under-represented in many health professions, including medicine, dentistry and

nursing. For example, 3% of active patient care physicians in Pennsylvania in 1998 were Black/African American, much lower

than the 10% of African-Americans in the general population.

As in most states, the infant mortality rate for Blacks/African Americans in Pennsylvania in 1996-98 was significantly higher

(15.7/100,000) than the rate for non-Hispanic whites (6.0/100,000) or Hispanics/Latinos (8.7/100,000).

Medicine

There were more than 28,000 active patient care physicians in Pennsylvania in 1998. With 234 physicians per 100,000

population, Pennsylvania was well above the national ratio of 198 physicians per 100,000 and ranked 7th among states in

physicians per capita.

Pennsylvania had 60 active primary care physicians per 100,000 population in 1998, compared to 59 per 100,000 for the entire

country.

Medical schools in Pennsylvania graduated 1,267 new physicians in 1997. On a per capita basis, Pennsylvania graduated more

new physicians per 100,000 population (10.5) than did the entire United States (6.6) and ranked 6th among the 46 states with

medical schools in medical school graduates per capita.

There were 1,597 physician assistants practicing in Pennsylvania in 1999. This was equal to 13.3 physician assistants per

100,000 population, above the national average of 10.4.

Nursing

There were over 160,000 licensed registered nurses (RNs) in Pennsylvania in 1996; nearly 123,000 were employed in nursing.

There were 1,014.9 RNs per 100,000 population in Pennsylvania in 1996, significantly more than the national average of 798.

Page 34 June 2004


References

Appendix A

Definition of rural/urban Census 2000

Source: The Center For Rural Pennsylvania

Rural/Urban PA

In 2003, the Center for Rural Pennsylvania adopted a definition of rural and urban based on population density. Population

density is calculated by dividing the total population of a specific area by the total number of square land miles of that area. In

2000, the population of Pennsylvania was 12,281,054 and the number of square miles of land in Pennsylvania was 44,820.

Therefore, the population density was 274 persons per square mile.

By basing the definition on population density, the Center for Rural Pennsylvania can now identify counties, municipalities,

and school districts as either rural or urban.

County or school district definition

A county or school district is rural when the number of persons per square mile within the county or school district is less than

274. Counties and school districts that have 274 persons or more per square mile are considered urban.

Municipal definition

A municipality is rural when the population density within the municipality is less than 274 persons per square mile or the

municipality’s total population is less than 2,500 unless more than 50 percent of the population lives in an urbanized area, as

defined by the U.S. Census Bureau. All other municipalities are considered urban.

Applying the definition

When applying the definition to counties, we find that 48 of Pennsylvania’s 67 counties are rural. In 2000, nearly 3.4 million

residents called these counties home, or 28 percent of the state’s 12.3 million residents.

At the school district level, 243 of the state’s 501 public school districts are rural. During the 2000-2001 school year, more than

522,000 public school students attended school in rural districts, or 29 percent of the state’s nearly 1.8 million public school

students.

At the municipal level, 1,655 municipalities are rural, or 64 percent of the state’s 2,576 municipalities. Rural municipalities are

found in every county except Delaware and Philadelphia. Forest, Fulton, Juniata, Pike, and Sullivan counties have no urban

municipalities. In 2000, more than 2.8 million people lived in a rural municipality, or 24 percent of the state’s 12.3 million

residents.

A slight difference in numbers

You may have noticed that there are more rural county residents than rural municipal residents. This difference has to do with

the different levels of government.

The county definition includes every resident living in every municipality in the county- both rural and urban. At the county

level, when the county is considered rural, then all of the residents in the county are considered rural.

On the other hand, the municipal definition only includes those residents who live in a rural municipality, regardless of whether

the county is considered rural or urban. Using this definition, it’s possible to have an urban municipality in a rural county and a

rural municipality in an urban county


June 2004 Page 35

References

Appendix A

Comparison of responses of Pennsylvania “Survey of RNs with license renewal due April, 2002", to Pennsylvania

“Survey of LPNs with license renewal due June 2002"; selected demographics and employment information


Page 36 June 2004


References

Appendix A

Comparison of responses of Pennsylvania “Survey of RNs with license renewal due April, 2002", to Pennsylvania

“Survey of LPNs with license renewal due June 2002"; selected demographics and employment information



June 2004 Page 37

References

Appendix A

Comparison of responses of national sample survey of registered nurses, March 2000, to Pennsylvania RN licensure

survey on selected demographics and employment information


Page 38 June 2004


References

Appendix A

Comparison of responses of national sample survey of registered nurses, March 2000, to Pennsylvania RN licensure

survey on selected demographics and employment information



June 2004 Page 39

References

Appendix A

The Workforce Strategy Map

Source: In Our hands: How Hospital Leaders Can Build a Thriving Workforce AHA Commission on Workforce for

Hospitals and Health Systems, 2003

Page 40 June 2004


References

Appendix A

Definitions of Practice and Information on the Educational Programs

for Selected Healthcare Providers

Registered Nurse

Legal Definition: The Practice of Professional Nursing (Registered Nurse): Diagnosing and treating human responses

to actual or potential health problems through such services as case finding, health teaching, health counseling, and

provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by

a licensed physician or dentist. The foregoing shall not be deemed to include acts of medical diagnosis or prescription

of medical therapeutic or corrective measures, except as performed by a certified registered nurse practitioner in

accordance with rules and regulations promulgated by the Board ((1) amended December 9, 2002, P.L. 1567,

No.206.)5

RN Education:8

RN Baccalaureate program (RN-BS): Four year college degree program of nursing developed under the authority

of a regionally accredited university or college.

RN Hospital-based diploma program (RN-DIP): Two to three year nursing diploma program developed under the

authority of a hospital accredited by the Joint Commission on accreditation of healthcare organizations.

RN Associate program (RN-AD): Two year college degree program of nursing developed under the authority of a

regionally accredited university or college.

Licensed Practical Nurse

Legal Definition: The practice of Practical Nursing is the performance of selected nursing acts in the care of the ill,

injured or infirm under the direction of a licensed professional nurse, a licensed physician or a licensed dentist which

do not require the specialized skill, judgment and knowledge required in professional nursing.” (Section 2 of

Pennsylvania Practical Nurse Act.)

LPN Education: Licensed Practical Nursing Program (LPN): a program for the education of practical nurses

developed under the authority of a hospital, educational institution or combination thereof. LPNs must be a high

school graduate and have satisfactorily completed a program in practical nursing prescribed and approved by the

board in a school, hospital or other educational institution, of not less than 1500 hours and within a period of not less

than 12 months, or have completed a program considered by the board to be equal to that required in the

Commonwealth at the time such program was completed. (Section 2 of Pennsylvania Practical Nurse Act)

Licensed Practical Nurses in Pennsylvania are regulated and licensed by the Pennsylvania State Board of Nursing

under the “Practical Nurse Law.”


June 2004 Page 41

Nurse Practitioners

Definition: Nurse Practioners are those RNs with additional education in an area of specialty, usually at the master’s

level of education. Licensure to practice as a NP or APRN differs from state to state. In Pennsylvania nurse

practitioners are licensed through the Board of Nursing.

Education: Most of the approximately 150 NP education programs in the United States today confer a master’s

degree. At least 36 states require NPs to be nationally certified by the ANA or a specialty nursing organization.

Nurse Midwives

Definition: A Certified Nurse-Midwife (CNM) is an individual educated in the two disciplines of nursing and

midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-

Midwives (ACNM).

Midwifery practice is based on the Core Competencies for Basic Midwifery Practice, The Standards for the Practice

of Nurse-Midwifery and the Code of Ethics promulgated by the American College of Nurse-Midwives. Certified

nurse-midwives (CNMs) and certified midwives (CMs) who have been certified by the ACNM or the ACNM

Certification Council, Inc. (ACC) assume responsibility and accountability for their practice as primary healthcare

providers. (ACNM Website http://www.midwife.org)

The ACNM defines the midwife’s role in primary healthcare based on the Institute of Medicine’s report (1996), the

ACNM philosophy (1989), and the ACNM Board of Directors’ Position Statement on Certified Nurse-Midwives and

Certified Midwives as Primary Health Care Providers/Case Managers (1997). Primary healthcare is the provision of

integrated, accessible healthcare services by clinicians who are accountable for addressing the majority of healthcare

needs, developing a sustained partnership with patients, and practicing within the context of family and community.

As primary healthcare providers, CNMs and CMs assume responsibility for the provision of, and referral for,

appropriate healthcare services that are within a defined scope of practice.

Clinical Education for Midwifery Students: Midwifery education is based on a theoretical foundation in the health

sciences as well as clinical preparation which focuses on the knowledge, judgment, and skills deemed necessary to

provide primary care and independent management of women and newborns within a healthcare system, that provides

for medical consultation, collaborative management, or referral as appropriate. This care, as defined by the American

College of Nurse-Midwives (ACNM), includes antepartum, intrapartum,

Education: The American Dental Association’s Commission on Dental Accreditation approved 248 dental assisting

training programs in 2000. Most programs take one year or less to complete and lead to a certificate or diploma. Two-

year programs offered in community and junior colleges lead to an associate degree. All programs require a high

school diploma or its equivalent, and some require a typing or science course for admission. Some states regulate the

duties of dental assistants through licensure or registration. Without further education, advancement opportunities are

limited (ADA website).

Page 42 June 2004


Dental Hygientist

Definition: A dental hygienist is a licensed healthcare professional, oral health educator, and clinician who, as a co-

therapist with the dentist, provides preventive, educational, and therapeutic services supporting total health for the

control of oral diseases and the promotion of oral health. A registered dental hygienist has graduated from a minimum

two-year college program that includes classroom studies and extensive supervised clinical experience. A dental

hygienist also must pass a national written exam and a comprehensive state or regional clinical exam to earn the RDH

license

Education: Schools offer laboratory, clinical, and classroom instruction in subjects such as anatomy, physiology,

chemistry, microbiology, pharmacology, nutrition, radiography, histology (the study of tissue structure),

periodontology (the study of gum diseases), pathology, dental materials, clinical dental hygiene, and social and

behavioral sciences.

Dental Assistant

Definition: In smaller practices, the assistant might work with the dentist, as well as managing the business aspects of

the practice such as scheduling, billing and purchasing. In larger practices the duties may be more specialized. Many

assistants are qualified to take X-rays. In most dental offices, the dental assistant is in charge of infection control

procedures, which are closely regulated by OSHA (the federal Occupational Safety and Health Administration). 19

They work chairside as dentists examine and treat patients. They make patients as comfortable as possible in the

dental chair, prepare them for treatment, and obtain dental records. They also may remove sutures, apply anesthetics

to gums or cavity-preventive agents to teeth, remove excess cement used in the filling process, and place rubber dams

on the teeth to isolate them for individual. Those with laboratory duties make casts of the teeth and mouth from

impressions. Some dental assistants prepare materials for making impressions and restorations, expose radiographs,

and process dental x-ray film as directed by a dentist.

Education: The American Dental Association’s Commission on Dental Accreditation approved 248 dental assisting

training programs in 2000. Most programs take one year or less to complete and lead to a certificate or diploma. Two-

year programs offered in community and junior colleges lead to an associate degree. All programs require a high

school diploma or its equivalent, and some require a typing or science course for admission. Some states regulate the

duties of dental assistants through licensure or registration. Without further education, advancement opportunities are

limited (ADA website).

Physician Assistants

Definition: Physician Assistants are healthcare professionals licensed to practice medicine with physician

supervision. PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive

healthcare, assist in surgery, and in most states can write prescriptions.

Education: PAs are trained in intensive education programs accredited by the Accreditation Review Commission on

Education for the Physician Assistant (ARC-PA). Because of the close working relationship PAs have with

physicians, PAs are educated in the medical model designed to complement physician training. Upon graduation,

physician assistants take a national certification examination developed by the National Commission on Certification

of PAs in conjunction with the National Board of Medical Examiners. To maintain their national certification, PAs


June 2004 Page 43

must log 100 hours of continuing medical education every two years and sit for a recertification examination every

six years. Graduation from an accredited physician assistant program and passage of the national certifying exam are

required for state licensure. (American Academy of Physician Assistants website http://www.aapa.org/geninfo1.html)

The Education Model: Applicants to physician assistant programs must complete roughly two years of college

courses in basic science and behavioral science as prerequisites to PA training. This is analogous to pre-med studies

required of medical students. Preference is usually given to candidates who have prior experience in healthcare. Most

PA students have earned a bachelor’s degree and have an average of 43 months of healthcare experience before they

are admitted to a program.

On average, PA education programs are 25.5 months in length. Educators of PAs include physicians, PAs and basic

scientists. Physician assistant education is characterized by an intense, yet practical curriculum, with both didactic and

clinical components.

The first year of PA education provides a broad grounding in medical principles with a focus on their clinical

applicability. This didactic curriculum typically consists of coursework in the basic sciences, including anatomy,

physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory

sciences, behavioral science and medical ethics. In the second year, students receive hands-on clinical training through

a series of clerkships or rotations in a variety of inpatient and outpatient settings. Rotations include family medicine,

internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine and psychiatry.

Physician assistant students complete an average of over 2,000 hours of supervised clinical practice prior to

graduation.

PA education is tightly structured and focused, recognized by many as highly innovative, efficient and effective. It is

competency-based, meaning that students must demonstrate proficiency in various areas of medical knowledge and

must meet behavioral and clinical learning objectives. Many other professions also offer competency-based degrees.

The MD, DO, DDS and JD degrees are competency based. (American Academy of Physician Assistants http://

www.aapa.org/gandp/paeduc.html.)

Nationally, 45 programs require a bachelor’s degree at the time of entrance or at graduation, and 76 a master’s degree;

sixty seven percent of the applicants had completed a minimum of a bachelor’s degree before applying;

Mean class size (first and second year students 2000-2001) 86.5 students,

65 % female/ 35% male;

Mean number of applicants per year 162 (2000-2001) up from 98.4 in 1984-1985;

average age is 28.2 years old.

General information excerpted from the 17th annual report on PA education in the United States providing regional

and nationwide trends

Page 44 June 2004


References

Appendix B

Numbers of Selected Healthcare Provider Schools in Pennsylvania Located in Rural Counties

Registered Nurses—Seven schools out of a total of 38 are located in rural counties

Associate Degree Nurses—Seven schools out of a total of 18 are located in rural counties

Diploma Nurses—Three schools out of a total of 23 are located in rural counties

Licensed Practical Nurses—Twenty one schools out of a total of 46 are located in rural counties

Dentists—Total of three schools all located in urban areas

Dental Hygienist—Total of nine schools all located in urban areas

Physician Assistants—Two schools out of a total of 14 are located in rural counties

Pharmacists—Total of five schools all located in urban areas


June 2004 Page 45

References

Appendix C

Considerations for Healthcare Workforce Issues

Nursing

Registered Nurses ................................................................................................................................................... 46–48

Licensed Practical Nurse .............................................................................................................................................. 49

Nurse Practitioners ....................................................................................................................................................... 49

Nurse Midwives ........................................................................................................................................................... 49

Dental Personnel

Dentists ......................................................................................................................................................................... 50

Dental Hygienists ......................................................................................................................................................... 50

Physician Assistants ............................................................................................................................................................. 51

Direct Care Workers ............................................................................................................................................................ 51

Public Health Personnel ....................................................................................................................................................... 52

For All Healthcare Providers ............................................................................................................................................... 53

Page 46 June 2004


References

Appendix C

Considerations for Healthcare Workforce Issues

Considerations for Registered Nurses

Numerous studies and reports have been produced with a spectrum of recommendations specific to the RN workforce but are

applicable to all levels of nursing. Many are already in the process of implementation including: increasing scholarship funds

for basic nursing; changes in the employment environment to increase retention; new educational models, recognition and

potential for professional advancement, and broad-based publicity to attract young applicants to the field of nursing. The

following presentation, reports address nursing workforce issues and suggested solutions.

Rebecca Beatty, RN, MS, D. Ed

Trouble in rural health care: Nursing shortage 2001

Presentation at Pennsylvania Rural Health Conference, State College, PA 2001. Rebecca Beatty, RN, MS, D. Ed,

Coordinator of Continuing Education, Penn State School of Nursing, study of seven rural counties in PA in 2001.

Professor Beatty identified the following keys to success for retention of nurses:

a. Leadership: Nursing leadership that is visionary and enthusiastic; supportive and knowledgeable; with high standards;

values education and professional development; holds power in organization; is highly visible; is responsive; has open

lines of communication; has active involvement in nursing organizations.

b. Change the work environment: Through flexibility in work schedules; through a safe workplace; with adequate

professional staff; with self governance; with fair pay; with respect; with adequate orientation; with mentoring; through

adequate educational opportunities; includes a seat at the decision making table and is loyal to employees.

c. Attributes of RN professional practice:

• Has the ability to establish and maintain therapeutic relationships with the patient;

• the ability to make decisions without interference;

• has control over their own practice environment;

• has collaborative nurse-physician relationships;

• has recognition for contribution to patient care;

• has job satisfaction.


June 2004 Page 47

Local and National Reports Addressing Workforce Issues for All Nurses:

“Pennsylvania Nurses: Meeting the Demand for Nursing in the 21st Century. 2002 Update”.

The Hospital & Health Systems of Pennsylvania.

This report states that “ Creating a culture that recognizes and supports the important role nurses have in patient care

delivery can result in higher nurse retention and job satisfaction, as well as improved patient outcomes and greater

satisfaction.”

It also outlined the factors that affect the supply and demand for nurses and called “for both public and private sectors to

become vested in developing solution to the nursing shortage” through the following actions:

a. Patient care delivery improvement and work environment improvement for nurses:

• Evaluate and implement models of patient care delivery that provide quality care;

• Recognize and utilize the professional expertise of nurses and create work environments that support

recruitment and retention of nurses;

• Collaboration of hospitals and nursing education programs to assist nursing students and new graduates in

gaining critical thinking skills and confidence;

• Investment by healthcare delivery systems and others to evaluate technologies, restructure the work

environment, and, innovative care design to improve patient safety and the work environment to allow

nurses to emphasize care giving.

b. Adequate funding for healthcare for competitive wages, and investment in technology to improve patient and worker

safety:

• Hospitals must be fairly reimbursed to enable them to pay salaries that are competitive, and to invest in

technology and systems of care to improve patient and worker safety.

c. Financial support for nursing and allied health education to sustain current schools of nursing.

d. Nursing Career Outreach to promote nursing and other health careers to the states diverse population:

• Nursing and allied healthcare organizations need to collaborate to promote nursing and other health careers

to the state’s diverse population.

e. Financial incentives for students, including loan forgiveness and scholarship programes:

• Ongoing loan forgiveness and scholarship programs to attract a diverse student population and encourage

graduates to work in professional shortage areas.

f. Healthcare workforce data collection and analysis in Pennsylvania:

• The state should take a comprehensive approach to data collection and analysis of healthcare workforce.

g. The regulatory environment:

• Better coordination among responsible agencies to avoid conflicting requirements and to provide

organizations sufficient flexibility to safely utilize personnel within the scope of their practice ability.

Page 48 June 2004


“Health Care’s Human Crisis: The American Nursing Shortage”. Robert Wood Johnson Foundation. April 2002.

This report takes a broad look at the underlying factors that are driving the nursing shortage in the United States and

summarizes the range of activities that a wide cross section of organizations are undertaking to address it.

The report calls for a re-envisioning of the nursing profession itself, so that it can emerge from this crisis stronger and in

equal partnership with the profession of medicine. Anything less, consigns nursing, and the public that depends upon its

care, to perpetual cycles of shortage and oversupply.

The authors (of the report) recommend that a national forum to advance nursing be created. This forum would create new

models:

• Redesign of nursing work environments, with a particular emphasis on using new technologies to

facilitate nursing practice.

• Nursing leadership: create new professional practice models; reinvent nursing education to better

prepare students for and reflect the current work environment.

• Establish a national nursing workforce measurement and data collection system to provide current,

consistent and comparable data that can be compared at a national, state and county level

longitudinally.

• Establish a clearinghouse of effective strategies to advance cultural exchange within the nursing

profession by creating a comprehensive, up-to-date webite that provides useful information for health

care leaders about research, programs and models that have proven successful in advancing the nursing

profession.

• Engage consumers, through a national forum, to advance nursing which would provide the necessary

structure to bring together all stakeholders in a collective effort to develop meaningful, lasting

solutions to the American nursing shortage.

“Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis”. Joint Commission on

Accreditation of Health Care Organizations. 2002.

The Joint Commission convened a multidisciplinary expert roundtable on the nursing shortage to analyze the problem and

to frame its solutions and identify accountabilities for these solutions. The participants focused on the principal factors that

have contributed to the shortage, the growing threat of the nursing shortage to patient safety, and the priority solutions

most likely to provide for a stable nursing workforce in the future.(Excerpt from introduction)

Recommendations based on Roundtable Discussions:

1) Create organizational cultures of retention:

• adopt the characteristics of “Magnet” hospitals to foster a workplace that empowers and is respectful of

nursing staff.

2) Bolster the nursing education infrastructure:

• increase funding for nursing education, including endowments, scholarships and federal appropriations;

• establish a standardized post graduate residency program;

• emphasize team training in nursing education;

• enhance support of nursing orientation, in-service and continuing education in hospital;.

• create nursing career ladders commensurate with educational level and experience.

3) Establish financial incentives for investing in nursing:

• make new federal monies available for healthcare organizations to invest in nursing services.


June 2004 Page 49

Considerations for Licensed Practical Nurses, Nurse Practitioners, and Nurse-Midwives

Licensed Practical Nurses

There is a need for:

• Increased LPN educational sites and student places (classroom space);

• Collegiate credit for courses taken in LPN educational programs;

• Seamless entry from LPN educational programs to collegiate RN programs.

Nurse Practitioner

Barriers to practice including:

• Limited access to patients due to legislative and regulatory restrictions;

• General lack of information about nurse practitioner education and practice parameters by consumers and

other healthcare professionals;

• HMO and other commercial health insurance policies that exclude NPs as providers of care or limit

reimbursement for services provided;

• Lack of support from the medical profession due to conflicting views on parameters of practice for NPs.

Nurse-Midwives

• Lack of prescription writing privileges;

• Lack of direct admitting privileges into hospitals for patients in labor;

• Lack of continuous representation on Board of Medicine (BOM). Midwives in PA are licensed by BOM;

• Exclusion from provider status with some commercial insurance companies and managed care organizations;

• Low reimbursement rates from some commercial insurance companies and managed care organizations;

• High malpractice insurance.

Page 50 June 2004


Considerations for Dentists and Dental Hygienists

Dentists

The following recommendations are excerpted from a presentation by Dr. Neil Gardner, DDS, MPH on Dental Workforce

Issues at the Pennsylvania Rural health Confrence, June 11, 2002.

Suggested solutions to better distribute the dental workforce:

• Make public programs more attractive with increased reimbursement and administrative simplification.

• Need research of patient’s real problems (in relation to access) and easier complaint processes (Act 68) with

tracking.

• Better training of dentists in cultural competency.

• Better training of dentists in treating children and the elderly.

• Training of more pediatric dental specialists.

• Need (wider) dental licensure reciprocity to allow freedom of movement of dentists to distribute more

evenly; Pennsylvania now gives reciprocity if other state does the same.

• Need more students in all dental educational settings from minority groups and underserved areas.

• Need increased loan repayment or tax incentives to locate and serve underserved populations.

• Need more local case management to help patients with transportation, complaints, and other issues, such as

training of underserved populations about dental office expectations and prevention issues.

• Increased safety net clinics where needed.

• Increased numbers of dental hygienists with expanded responsibilities will help to meet the needs

• Expansion of the numbers and functions of dental assistants (EFDAs) will help to meet the needs.

• Need more oral health prevention taught in primary care settings.

• Need to assure that more dentists are on advisory committees and government policy boards.

Dental Hygienists

Goals:

• Achieve autonomy of dental hygiene education, licensure and practice

• Promote consumer advocacy in oral healthcare as part of total health

• Serve as the recognized authority for the profession of dental hygiene

Recommendations:

••••• Provide preventive and periodontal services without direct supervision of a dentist. Under current statute in

Pennsylvania, dental hygienists are unable to provide care in a private setting unless the dentist is physically present

on the premises. In certain public health settings, a dental hygienist may practice under general supervision, as long as

the dentist has completed an examination within a 90-day period. This does not mean that a dental hygienist will

practice independently of a dentist. The dentist could be accessible by telephone or Internet, offering the opportunity

for exchange of dialogue and referral for evaluation if needed.

••••• Reintroduce the school dental hygienist. Most school districts employed dental hygienists in the past, but due to

financial problems these positions have been eliminated. The school dental hygienists could provide at least annual

oral health screenings, oral health education, oversee a fluoride rinse program, place sealants and make referrals for

dental treatment if needed. Prevention and early assessment will decrease the number of school days lost due to dental

pain and the caries rate. This recommendation makes sense in relation to the data on the lack of dental care for

children in many areas of Pennsylvania.

••••• Implement a mobile van that could travel into rural areas as needed for routine screenings and minor treatment.


June 2004 Page 51

Considerations for Physician Assistants

While the Commonwealth has allowed physician assistants to write prescriptions, restrictions are not consistent with the

education and expertise of the position, and serve as a barrier to full utilization. This especially effects rural primary care PAs

who are prohibited from prescribing medications for the treatment of asthma and other common diseases.

• The Commonwealth currently limits the ability of physicians to supervise more than two physician assistants. While

the law was well intended to assure appropriate levels of supervision, it prohibits practices the flexibility of hiring

part time PAs.

• Additionally supervision requirements such as mandating the physician to see the patient every third visit creates a

administrative barriers to full utilization and inhibits access for patients to medical services.

• While satellite clinic provisions are available within the Commonwealth these same restrictive supervision

requirements prevent practices from deploying physician assistants into MUA/HPSA sites that are geographically

and/ or manpower shortage areas.

• Medicaid, Medicare, and many private insurers recognize physician assistants. While physician assistant certification

within the Commonwealth represents “de-facto” licensure as defined by the state attorney general’s office, lack of

licensure prevents reimbursement from some private insurers for medical services provided by physician assistants.

With the passage of Act 160 in 2002, which licenses physician assistants, negotiations are currently underway to

correct this restriction.

Considerations for Direct Care Workers:

A national association called the Direct Care Alliance, formed in 1998, echoes the concerns of the MH/MR Coalition in

Pennsylvania. The Alliance states that we face a nationwide critical shortage of high-quality direct-care worker who can meet

the needs of our country’s long-term care consumers. Direct-care workers provide the vast majority of hands-on care within our

long-term care health system. They cite five areas of concern to meet the shortage and turnover of direct care workers:

• Inadequate wages and benefits: many direct caregivers live below the poverty level. These conditions lead to higher

turnover, labor shortages, and an over-reliance on inexperienced caregivers or temporary workers.

• Unreasonable workloads

• A poorly trained paraprofessional workforce: A higher set of training standards is now needed to better prepare

paid caregivers for all the services they must deliver to clients. The training must move beyond skill development to

include competencies in communications, problem solving and decision making.

• Poor supervision and job quality: When asked to identify factors that contribute to “good working conditions,”

paraprofessionals most often cite: supervision that is consistent, fair and knowledgeable; opportunities to receive the

education they need to do their job well; supervisors who respect their observations of client status and listen to what t

they have to say; inclusion as equal members of care teams and in care planning; and access to the equipment and

supplies they need.

• Absence of accurate data to document quality care:. The government, through the federal Health Care Financing

Administration and state Medicaid departments, pays for 70 % of long-term care services. These public administrative

departments, however, do not track what percentage of their reimbursement goes directly to salaries and benefits for

direct-care workers. Having access to accurate data on direct-care workers’ pay and benefits, along with other

workforce indicators, such as turnover rates, ratios of workers to residents and workers to supervisors, and number of

training hours per year, would assist the government in assessing provider quality.

• No presence in policy discussions. Although para-professional workers are critical to our long-term care service

delivery system, they have been neglected in policy discussions.

Page 52 June 2004


Considerations for Public Health Personnel

Pennsylvania ranks last among states, with only 37 public health workers per 100,000 population. This can likely be traced to

infrastructure development decisions which have led to Pennsylvania having only 10 independent health departments (all in

urban areas). The remainder of the state lacks a local public health infrastructure, and therefore the entities through which

additional public health workers would be employed. It should be noted that this does not necessarily mean that public health

services are entirely lacking in rural areas. Rather, hospitals, agricultural extension offices, voluntary organizations and others

are likely fulfilling a number of public health functions. The challenge, however, is that public health services provided by

these entities are not uniformly provided across communities and there is little coordination with state and independent health

departments. Without the necessary public health infrastructure it is difficult to monitor these efforts and assure that essential

public health services are being provided to all Pennsylvania’s citizens.

It should also be noted that Pennsylvania’s public health infrastructure is unique among states in this region. Surrounding

states have all opted to create a locally based system of public health agencies covering each county in their state. As a result,

per capita numbers of public health workers are higher in each of these states (NJ 65/100,000; OH 67/100,000; NY 73/100,000;

WV 244/100,000; MD 304/100,000). [Note that NJ has a local public health system based at the township level rather than the

county level.]

While causality is difficult to determine, Pennsylvania faces a number of issues that may result from the low number of public

health workers. At the very least, it is safe to say that a stronger public health infrastructure with an adequate supply of public

health workers will be a critical component to addressing these issues, which include the following:

• Pennsylvania ranks second in the nation for overweight and obesity;

• Pennsylvania ranks third in the nation for number of Super Fund sites;

• Pennsylvania ranks seventh in the nation for low birth weight infants;

• Pennsylvania ranks seventh in the nation for number of AIDS cases;

• Pennsylvania ranks ninth in the nation for the number of teen births;

• Pennsylvania ranks in the top 90% among states for carcinogenic and non-carcinogenic air and water releases; and

• Pennsylvania ranks in the bottom half of all states for high rates of inadequacy of prenatal care, cancer cases, heart

disease, infant mortality and premature death, infectious diseases, smoking, total mortality and violent crime.


June 2004 Page 53

Considerations For All Healthcare Providers

Of all of the reports cited, the following is the most broad-based and comprehensive. The recommendations are encapsulated in

a “Workforce Strategy Map”, which clearly outlines the problem, the commission charge and keys to solving the workforce

shortage.

“In Our Hands: How Hospital Leaders Can Build a Thriving Workforce”. AHA Commission on Workforce for

Hospitals and Health Systems. 2002.

The Commissions’ charge was to develop bold goals and actionable recommendations for the following:

• Increase recognition that people are a key, strategic resource.

• Fully value and invest in retention, recruitment and development of caregivers and support personnel.

• Expand interest in healthcare careers and educational programs.

• Make hospitals and health systems “employers of choice.”

Recommendations:

• Foster meaningful work: Make work design an organizational priority and competence; develop new work

designs; assure enough qualified staff for safe, timely care; create the capacity to keep all staff up-to-date; partner

with business on new work models.

• Improve the Workplace: Create a culture in which all workers feel valued: measure, improve, and reward the

capabilities of frontline managers; learn what makes workers become long-term employees; develop a

comprehensive rewards strategy that includes competitive edge in compensation, flexible benefits, employee

recognition, career development; increase personal control over assigned hours; give human resources the same

governance and senior leadership attention as finance.

• Broaden the base : Aggressively develop a more diverse workforce pool; create attraction strategies for each

generational cohort; pursue people from the full range of potential sources; communicate a positive, satisfying and

inspiring image of healthcare providers.

• Collaborate with others: Collaborate with other hospitals on community-based workforce solutions; partner with

associations to develop and enhance initiatives; collaborate with K-12 education to build student interest in health

careers; build strong relationships with area colleges and universities; partner with community organizations to

attract students; work with local workforce development councils; work with other hospitals to retain workers in

the healthcare field.

• Build societal support: All payers must contribute to workforce development; all payers must recognize real labor

costs; government and the private sector should support technology to facilitate work improvement; government

regulations should minimize the administrative burden on workers; regulations should facilitate care by the right

person doing the right task at the right time; retirement policies need to change to encourage older workers to keep

working; education needs to emphasize interdisciplinary training; provide consistent resources for workforce data

collection, analysis, and publication.

Page 54 June 2004


Prepared by Members ofPennsylvania Rural Health Association’s

Healthcare Workforce Issues Sub Committee:

Sister Teresita Hinnegan, Chair

Norine Chilotas

Walter Eisenhauer

Corrine Klose

Michael Meit

Ronal Mezick

Al Speth

Steven Urban

Susan Weinand

Peggy Yurcho

Pennsylvania Rural Health AssociationP.O. Box 1632

Harrisburg, PA 17105-1632(717) 561-5248

http://porh.cas.psu.edu/prhaweb/prhahome.htm

Documents

The Healthcare Workforce in Rural Pennsylvania