RURAL NURSE PRACTITIONERS:
RHAC SURVEY RESULTS
Presentation to Rural Health Advisory Committee & Flex Committee
May 19, 2015
Review: Minnesota regions
Review: NPs vs population, by Minnesota region
2015 licensed NPs (n=3,867)
2013 population estimate (n=5,420,380)
54%
46%
17%
14%
14%
11%
7%
4%
7% 6%
2%
Central
West Central
2%
Northland
6%
5%
3%
Northwest
3%
Southern
Southwest
Twin Cities
Source: Minnesota Board of Nursing licensing data (May 2015) and U.S. Census Bureau, Decennial Census (2013).
Out of state No business
address
Review: Rural-urban commuting areas (RUCAs)
Review: NPs vs population, by rural-urban distribution
Source: Minnesota Board of Nursing licensing data and U.S. census data, 2010.
RHAC NP survey
• In Sept 2014, surveys sent to 402 rural facilities
• 79 Critical Access Hospitals (60% response rate)
• 87 federally designated Rural Health Clinics (40% response rate)
• 236 other rural clinics (21% response rate)
• Of the clinics responding:
• 10% were in “large rural” areas
• 34% in “small rural” areas
• 46% in “isolated rural” areas
• CAHs are also distributed among all three rural types, and
most of these are also in small and isolated (vs. large)
rural areas.
Survey: How many NPs on staff?
CAHs
Clinics
80% employ at least 1 NP.
84% employ least 1 NP.
Of these:
• 47% employ 3 or fewer NPs.
• 33% employ 4 or more NPs.
Of these:
• 80% employ 3 or fewer NPs.
• 16% employ 4 or more NPs.
Clinics in small and isolated rural
areas are more likely than those
in large rural areas to employ
only 1 or 2 NPs.
Survey: What % of your primary care
workforce is NP/PA/MD?
Average % of each provider type, CAH v clinic
CAHs
(n=42)
Clinics
(n=79)
NP
27%
NP
29%
PA
18%
NP
16%
MD
54%
MD
55%
Survey: In which departments do NPs work?
Number of facilities using NPs in these departments
Family medicine
9
Emergency medicine
Geriatrics
Mental health
19
38
14
20
OB/GYN
Urgent care
71
23
5
33
1
18
2
32
Diabetes
30
Pediatrics
28
Family planning
26
Internal medicine
12
Other specialties*
Med/surg
Intensive care
CAHs
(n=47)
21
Pain medicine
LTC/nursing home
Clinics
(n=71)
14
*Other specialties include: Oncology,
orthopedics and nephrology.
2
3
Survey: In which clinic departments do NPs work?
Family med
12
Geriatrics
9
Urgent care
12
7
Diabetes
5
Peds/Adol
5
Family planning
25
Internal med
17
9
14
11
14
10
3
13
10
8
32
13
10
7
Large rural
Pain med
3
7
10
Small rural
Mental health
OB/GYN
2
3
Emergency
11
medicine
Other specialties
8
3
4
7
8
7
4
3
Isolated rural
Survey: Certified as a Health Care Home?
Clinics vs. CAHs
Survey: In process of HCH certification?
Clinics vs. CAHs
Survey: Certified as a Health Care Home?
Survey: Do you use NP-led teams for care coordination?
Clinics vs. CAHs
No
77%
No
79%
Yes
23%
Yes
21%
Clinics (n=64)
Hospitals (n=19)
Survey: Do you use NP-led teams for care coordination?
Clinics only, by rurality
No
70%
No
76%
No
100%
Yes
30%
Large rural (n=9)
Small rural (n=23)
Yes
24%
Isolated rural (n=29)
Survey: Do NPs have admitting privileges in your
hospital?
Survey: Challenges to recruiting NPs?
Clinics vs. CAHs
No
67%
No
70%
Yes
33%
Yes
30%
Clinics (n=82)
Hospitals (n=44)
Survey: Challenges to recruiting NPs?
Clinics only, by rurality
No
79%
Yes
21%
Clinics in large rural (n=14)
No
68%
Yes
32%
Clinics in small rural (n=28)
No
61%
Yes
39%
Clinics in isolated rural (n=36)
Survey: Challenges to recruitment
• Most common by far: Rural location
• Lack of amenities, lack of work for spouse, lack of housing.
• Distance, esp. for remote sites requiring staff to be away from
home for 1-2 days when on call. Tough for new grads especially.
• ER call and other hospital care hours as part of job.
• Lack of rural experience: Candidates often right out of
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school, so training takes a long time.
Level of independence required; limited MD oversight.
Tight job market – lots of offers/opportunities for NPs.
Salary issues, including expectations w/doctoral degree.
No physician on staff willing to supervise.
Transitioning to a Advance Practice ER model with robust
e-tele support.
Survey: Incentives used in recruitment
70% of clinics and 64% of hospitals report using some kind
of incentive in recruiting NPs.
Incentives used:
• Sign-on bonus: 28% of clinics, 47% of CAHs
• Loan forgiveness: 38% of clinics, 43% of CAHs
• Cover cost of collaborative management agreement: 30% of clinics,
9% of CAHs
• Other (each used by fewer than 5% of facilities)
• Moving expenses
• Certification bonus
• Internships/practicum experiences
• Flexible hours
Survey: Challenges to retaining NPs?
Clinics vs. CAHs
No
79%
No
76%
Yes
21%
Yes
24%
Clinics (n=77)
Hospitals (n=42)
Survey: Challenges to retaining NPs?
Clinics only, by rurality
No
100%
No
81%
Yes
19%
Large rural (n=14)
Small rural (n=28)
No
70%
Yes
30%
Isolated rural (n=36)
Survey: Incentives used for retention
80% of clinics and 62% of hospitals report using some kind
of incentive to retain NPs.
Incentives used:
• Continuing education budget: 75% of clinics, 53% of CAHs
• Advanced training opptys: 34% of clinics, 26% of CAHs
• Tuition assistance: 21% of clinics, 26% of CAHs
• Cash bonuses: 17% of clinics, 19% of CAHs
• Cover cost of collaborative mgmt agmt: 34% of clinics, 15% of
CAHs
• Mentor program: 16% of clinic, 9% of CAHs
• Other (each used by less than 5% of facilities)
• Flexible scheduling
• As an FQHC with flat rate, can focus on patient care, not volume
• Exploring cash/quality bonuses
Survey: Recruitment and retention recommendations
• Policy-level Address challenge of CMS rules for emergency rooms and other
services require supervision levels by physicians not consistent with MN's Nurse
Practice Act.
• Practice-level
• Team approaches
• Monthly Medical Staff meetings.
• Involvement of NPs in performance and process improvement: e.g., Monthly Drug Formulary
review with team; and Post-Trauma Huddle.
• Good collaborating physicians. “MD attitudes toward the FNP needs to be one of
collaboration and respect.” Examples of MDs not agreeing NPs should admit pts even when
they have admitting privileges, or a bias toward hiring MDs vs. NPs.
• Compensation: Increase pay, esp. starting wages; reimburse
mileage.
• Increase office visit times.
• Increase administrative time to get charting done.
• When covering call and clinic, establish guidelines where clinic
visits are walk-in only.
Survey: Recruitment and retention recommendations, cont.
Educational programs
• Expand enrollment in NP programs.
• Encourage NP programs at community colleges and/or remote (online).
• Create rural health care track or courses.
• Create an NP-to-MD track.
• Require that part of NP education be in a CAH and in a shortage area.
• Require a residency - NP training is limited to observation and is limited in scope.
• Expand number of training sites.
• Expand loan forgiveness programs.
• Create Additional incentives for individuals to go back to school to obtain NP or
PA licenses, with incentives for practicing in rural areas.
In-house educational/training support
• “Grow your own”: Set up an RN-to-NP loan payback program with paid time off
for education.
• Mentoring new hires has been very successful.
• Provide CALS or ATLS training - gives greater sense of security in ER.
• Provide training early on in the Electronic Health Record system.
Survey: Would your CAH be interested in a distance
education/hybrid model NP residency program?
No
58%
Yes
42%
n=43 Critical Access Hospitals
Survey: Suggestions for such an NP residency
program?
• Inpatient/acute care training.
• Trauma training such as CALS – this would “ramp up”
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observation of rural ER care.
OB and/or surgery as part of the rural rotation.
Admission/discharge abilities.
Mentorship.
Online training.
Assistance with tuition/loan payback.
Allow CAHs to sponsor an NP for an ER residency in a
tertiary facility in exchange for years of service postresidency.
Discussion
Reactions?
Next steps?