Volume 9 Number 1
The Edna G. tugboat in Two Harbors.
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Spring 2007
The mission of the Office of Rural Health & Primary Care is to promote access to
quality health care for rural and underserved urban Minnesotans. From our unique position
within state government, we work as partners with communities, providers, policymakers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Pipeline Power
We all know there are worker shortages in health care. In some disciplines there are too few
workers, period, and in others there are challenges filling jobs to serve certain locations or
populations. It’s becoming old news that many in the health care workforce will soon retire,
that too few new workers are being trained to replace them and that demand for services is
growing. And across the spectrum, from home health aides to specialty physicians, health care
employers must compete with each other and with many other fields.
The workforce development projects featured in this issue are models that prove progress
is possible and solutions can be found. Each deserves to be supported and replicated
throughout the state. I hope the articles will give you some ideas for projects in your
community or organization.
DIRECTOR’S CORNER
Mark Schoenbaum
It’s tempting to latch on to a promising strategy, like those reported here, as the fix for our
workforce problems. But the problem is a complex one, with many moving parts. A common
analogy used to illustrate the breadth of the workforce development process is that of a pipeline,
which I’ve come to call the Health Care Safety Net Workforce Development Pipeline. From
beginning to end, the sections are:
• Expose elementary and secondary school students to health careers and prepare them in
math and science.
• Recruit traditional and nontraditional students into health careers training.
• Locate education and training programs, especially clinical training experiences, in high
need settings.
• Encourage graduates to seek employment in high need settings.
• Retain the safety net workforce.
Like any pipeline, the workforce development pipeline can be subject to leaks and bottlenecks,
and the process of deciding on a career or job is multifaceted. Kids with good math and science
skills have lots of choices, from designing buildings to designing video games, and may “leak” to
those fields and others. The shortage of nursing and other health faculty is clearly a bottleneck
to producing more graduates, and colleges and universities need a pipeline of their own to
obtain enough faculty. Once trained, attracting workers where they’re most needed remains a
challenge. For example, loan forgiveness program participants reported in this issue that top
factors in choosing their job location were the job of their spouse or partner, extended family in
the area and closeness to home.
The pipeline can also be replenished along its route, from sources such as new immigrants and
foreign-trained workers. Action is needed all along the pipeline from many partners—the
elementary and secondary school system, higher education, voluntary organizations like Scouts
and 4-H that offer career exploration; and employers, government and professional associations
and even family members, as mentors and advisors.
It’s easy to forget that there’s an appealing story to tell about working in rural and inner city
areas. I regularly hear from those working in the health care safety net that they find great variety
and the opportunity to use the range of skills and knowledge they learned during training.
The projects in this issue each fall someplace along the pipeline, and it will take interventions
and interaction along the entire pipeline to have the impact we’re going to need to staff the
health care system. Each strategy is needed, though I don’t think we’re going to find a Lone
Ranger or silver bullet to solve our health workforce problems. But by investing all along the
workforce pipeline, we can make a real difference.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care. He can be
reached at [email protected] or (651) 201-3859.
2
By Doug Benson and Katherine Cairns
Attracting qualified health care providers to rural
Minnesota has always been a challenge. In 1990, the
Minnesota Legislature created a Loan Forgiveness Program
to encourage physicians to practice in rural Minnesota in
exchange for payment of a portion of their medical school
loans. The placements began in 1992. In 1993, the
program was expanded to include midlevel practitioners
(nurse practitioners, physician assistants, clinical nurse
specialists and nurse midwives) and nurses who would
practice in nursing homes and/or intermediate care
facilities for the mentally retarded (ICFMR). In 2001, the
program was further expanded to include dentists and in
2005, pharmacists and health careers faculty.
The Minnesota Loan Forgiveness Programs provide
approximately $1.3 million annually to improve
distribution of health care practitioners in rural Minnesota
and in targeted clinics, nursing homes and educational
institutions. Through January 2007, a total of 579
providers and educators accessed the Minnesota Loan
Forgiveness Programs, with over 300 hospitals, nursing
homes, clinics, pharmacies, dental practices and allied
health and nursing training programs using the program as
a recruitment incentive.
Occupations selected for Loan Forgiveness Programs are
based on legislative funding authorized to expand
recruitment for critical health care providers and
educators. Occupations supported with state funding for
loan forgiveness include the following:
• Physicians are supported in their choice of primary
care practice in rural communities and a separate
program exists for primary care physicians practicing
in medically underserved urban areas.
• Nurse practitioners, nurse midwives, nurse
anesthetists, advanced clinical nurse specialists
and physician assistants are recruited for rural
practice through the rural midlevel practitioner loan
forgiveness program.
• The nurses loan forgiveness program targets licensed
practical nurses (LPN) and registered nurses (RN) in
training who agree to work in nursing homes or
ICFMR facilities.
• The dentist loan forgiveness program helps those
agreeing to work in rural or urban clinics with 25
percent of annual patient encounters being public
program enrollees or sliding fee schedule recipients.
• Pharmacists in the loan forgiveness program agree to
work in rural pharmacies.
• Allied health and nursing faculty participants are
teaching nurses, respiratory therapists, and
practitioners in clinical laboratory technology,
radiologic technology and surgical technology.
The Office of Rural Health and Primary Care is completing
a formal evaluation of the Minnesota Loan Forgiveness
Program, following up on a previous evaluation conducted
in 1999. A sample of the over 300 sponsoring health care
facilities and educational institutions from the past eight
years and all 407 of the past participants who completed
the program were surveyed.
Preliminary results from the evaluation, conducted by
Summit Health Group, confirm some of the findings from
the 1999 study. The results suggest that loan forgiveness is
an effective tool for attracting and retaining health
professionals in underserved communities. For example:
• The majority of responding physicians (84 percent),
who completed their rural service obligation (three
years), remained at their practice site after their
obligation ended.
• More than 80 percent of the midlevel practitioners
responding to the survey, who completed their
service obligation, had remained at their rural
practice location.
• Ninety-five percent of the responding nurses, who
completed their service obligation, remained at their
nursing home or ICFMR site following completion of
the Loan Forgiveness Program.
PROGRAM FOCUS
Minnesota’s Loan Forgiveness Program: Is it working?
The study also highlights information that may suggest
areas for program emphasis, including:
• The decision to specialize in primary care for the
majority of responding physicians was made in the
first through third year of medical school. A majority
of responding physicians made the decision to
practice in a rural area between high school and the
third year of medical school.
• The two most important factors in selecting a rural
site were a broader practice scope and natural
resources/recreation.
• A majority of responding physicians (64 percent)
reported that additional incentives included a signing
bonus or loan forgiveness.
• The two most important factors for midlevel providers
selecting a rural practice site were transportation/
close to home and the job of a spouse/significant other.
• Transportation/close to home and having extended
family in the area were the two most important
factors in selecting a practice site for nurses agreeing
to practice in nursing homes or ICFMR. Many of the
responding nurses indicated they were already
employed at the nursing home or ICFMR and were
encouraged by staff at the facility to complete
education/training for an LPN or RN license with the
loan forgiveness program as an added resource.
See “Minnesota’s Loan Forgiveness Program”
(back page)
3
PARTNER FOCUS
Educating our health care workforce:
By Valerie DeFor
Ask any rural health care employer for the best source of health care workers, and they’ll tell you it’s their own community.
With 32 colleges and universities in 46 communities, the Minnesota State Colleges and Universities (MNSCU) system is a
natural partner to help communities “grow their own.” This article highlights three initiatives designed to improve health
care education, health care delivery and ultimately the health of the citizens of Minnesota.
Luverne
Southwestern Minnesota’s newly-created Luverne
Educational Center Health Careers is an example of a truly
successful community partnership. A collaboration of
Sanford Health (formerly Sioux Valley Health), Minnesota
West Community and Technical College and the Luverne
Economic Development Authority, the Educational Center
for Health Careers, located in the former home of the
Luverne Hospital, provides a facility specifically designed
to meet the existing and projected needs for health care
workers and medical support staff. The Center will
educate about 14 radiologic and 20 surgical technology
students when it opens in the fall of 2007. There will also
be an associate degree in liberal arts offered with plans to
add more programs in the future. For example, Minnesota
West may expand their course offerings to include
certificate and diploma programs, such as medical coding
and medical secretary, currently offered at other Minnesota
West locations. Starting in summer 2007 general
education courses will be offered at the site.
the new hospital, valued at $200,000. Minnesota West
received about $50,000 in additional grant money. The
money raised from these sources is being used to purchase
equipment, develop curriculum and sustain the program
for two years. The partnership goes beyond the facility.
Minnesota West and Sanford Health will split the surgical
tech faculty member’s time, an innovative solution to the
need for faculty.
The former hospital building is well suited to teach future
health care professionals. Dr. Wood recalls, “When
walking through the old hospital for the first time, I got as
excited as a kid in a candy store.” Operating rooms and
prep rooms are available to the surgical technology
students. Radiology equipment is in the space. One third
of the building will be used to deliver courses. The city of
Luverne renovated about one third of the building for its
city offices. The remainder of the building, which was the
patient wing, offers the potential of being used as a dorm.
Owatonna
Luverne Education Center in Luverne, Minnesota.
The partnership began when the City of Luverne
approached Minnesota West Community and Technical
College with a vacant hospital and an idea to offer classes
through Minnesota West. Sanford Health then joined the
partnership. According to Dr. Ronald Wood, President of
Minnesota West, the city of Luverne committed $200,000
to the project. Sanford Health donated real estate close to
4
Riverland Community College in Owatonna provides a
great example of a technology-driven partnership to
improve health care education and delivery. In October
2005, Riverland received a $2.2 million grant from the
U.S. Department of Labor to construct a Health Simulation
Lab and develop needed health care programs for the
region and to provide training to health care providers.
Many partners, including other system institutions, health
Greater Minnesota’s innovative solutions
care providers, and the regional workforce development
office collaborated to bring the simulation lab to fruition.
As Dr. Brian Bunkers, Owatonna Clinic’s chief executive
officer, said, “The benefit to our community and patients is
obvious when those new graduates take care of you on
your next clinic or hospital visit.”
experience nursing roles in the hospital, emergency room,
ambulatory clinics, schools and public health settings,
among others. Student will work alongside their mentors
to integrate all the experiences of rural health care into a
comprehensive, meaningful practicum.
The simulation lab features computer-driven mannequins
complete with lifelike chest movements, heart and lung
sounds and vocalizations. Students in the Riverland
nursing and radiography programs use the simulation
mannequins to practice skills in situations they might not
encounter during clinical experiences. The technology also
allows students to review the simulation by video in
nearby classrooms or on personal computers through the
World Wide Web.
In addition to educating new students, the simulation
center is used to advance the skills of incumbent health
care workers and to provide continuing education.
Besides a rural focus, the Bemidji State baccalaureate
nursing program also focuses on transcultural competency,
emphasizing service to the area’s American Indian
populations. Bemidji State’s region encompasses six Indian
reservations. Faculty at Bemidji State work with individual
tribes to provide culturally competent non-Indian nurses,
as well as increasing the number of nurses of American
Indian descent. Through these educational efforts, Bemidji
State will help address the health care disparities of
Minnesota’s American Indian population.
Bemidji
In response to the needs of the health care providers in
north central Minnesota, Bemidji State University is home
to the newest of the system’s baccalaureate nursing
programs. Bemidi State’s program has been developed
with a rural focus, and, in particular, a focus on cultural
competency. The program, which will enroll 40 students
in fall of 2008, will thread rural health concerns and
cultural diversity throughout its curriculum, culminating in
a senior year capstone experience. Students will explore a
rural community and experience how health care is
delivered in a rural community. Relying primarily on
communities with Critical Access Hospitals, students will
It is well known that those who come from rural
communities, or are exposed to rural experiences, are
likely to be the most committed to becoming and staying
part of the rural health care community. And local
communities are often the best at finding ways to identify
and educate their own future health care workforce. In
2006, programs in the community-focused MNSCU
system graduated 78 percent of all nursing graduates and
45 percent of all allied health graduates in the state.
Valerie DeFor, M.H.S.A., is the director of the Healthcare
Education Industry Partnership, a Minnesota State
Colleges and Universities program hosted by Minnesota
State Mankato. Since 1998, HEIP has been working with
Minnesota’s health care educators and health care
providers to identify and solve health care workforce
issues. The HEIP Web site is www.heip.org
5
COMMUNITY FOCUS
Preceptors: Offering rural experiences
With special thanks to Kelly Goeb, M.D.; Paul Iverson, R.
Ph.; Diane Muckenhirn, R.N., M.S.N., C.N.P.
Practicing health care providers in rural Minnesota have
an opportunity to bring students of nursing, medicine and
pharmacy to their communities and health care facilities
by being a preceptor. The goal is to help students achieve
excellence in health care delivery by being in a learning
lab within clinics, hospitals and pharmacies. With an
enriching experience, the opportunity may also lead to
future employment.
Pharmacist Paul Iverson says, “We began taking students
because we felt our practices were somewhat unique and I
wanted to show students that you can practice clinical
pharmacy in a rural community practice. One of my
biggest surprises was the diversity of students. We’ve had
students from northern Minnesota and the Twin Cities,
other states and three other countries. In the early years
the students spent 10 weeks at our pharmacies. Now they
do three five-week rotations in the Bemidji area and spend
five to 10 weeks at our pharmacies. By exposing future
pharmacists to our practice and the quality of life in
“It keeps me sharp, I’m
helping, it’s great for the
students and my patients
understand the importance—
but most of all I’m giving back
and it feels really good.”
—Minnesota physician assistant
Bemidji we believe it will be easier to recruit pharmacists.
We have hired two former students as pharmacists in the
past 14 years.”
A preceptor is a clinical role model and a resource, who
provides support and guidance to students during clinical
placement. Preceptors work closely with students to plan
the orientation, clinical practice/learning experiences,
monitor progress, provide feedback on performance and
help the student feel welcome and integrated into the
practice setting.
6
While precepting is designed to enhance student learning,
an important byproduct is the value to the preceptor.
Iverson explains, “Having students has benefited all of our
pharmacists. The students challenge us with good
questions, particularly by asking ‘why?’ The students share
the latest, most up-to-date drug therapy information that
they receive from the faculty at the University.”
Programs
The Rural Physician Associate Program (RPAP) is a
community-based, nine-month elective for third-year
medical students enrolled in the University of Minnesota
Medical School at the Twin Cities or Duluth campuses
interested in primary care in rural Minnesota. Students
experience:
• Physician mentoring
• Full care with patients of all ages
• Continuity of patient care and
• Hands-on learning.
Students live and train in non-metropolitan communities
under the supervision of family physicians and other
physician preceptors. Some students rent apartments,
house sit for snowbirds, or if they are returning to their
family community, they often live at home.
RPAP students learn clinical medicine, procedures,
community health and the business of medicine while
developing relationships with physicians and patients.
Established in 1971, the goal of RPAP is to encourage
students to practice in rural areas throughout Minnesota.
Over 1,000 students have participated in the program;
two out of three former students still practice in rural
Minnesota and four out of five are in primary care.
RPAP also administrates the Rural Observation Experience
(ROE) for first and second year medical students at the
University of Minnesota Medical School-Twin Cities
Campus. The ROE is a two- to three-day opportunity for
students to observe the life of a rural physician.
Imagine spending your day at the clinic, sitting down to
dinner with the family and then going to the doctor’s
youngest child’s soccer game, and then being roused for
calls in the middle of the night—that is ROE. Students
move into the preceptor’s home for three days at a time,
three times a year. During the students’ stay they live the
doctor’s life and whatever that entails. For some students, it
is just the experience they need to make all the pieces fall
into place—the ah ha! moment of I can make this work!
Kelly J. Goeb, M.D. is in family practice at Gateway
Family Health Clinic-Sandstone. As a student, ROE was a
to health care students
revelation to Dr. Goeb and to her fellow second-year
medical school colleague—they are now one of four
physician couples practicing within the four Gateway
Family Health Clinic sites. Dr. Goeb and her future
husband saw the reality of a married physician couple
with children—real people, not only “dedicated
professionals”—who were able to blend a full private life
with a satisfying professional life.
“The art of caring for the patient is
the most important piece I hope
the student gains.”
—Diane Muckenhirn
Challenges
Having students in a practice does take time. The
preceptor needs to meet with them regularly and take
time to show them interesting cases and answer questions
as they come up. Also every student is different. The
preceptors agreed that the students who are excited and
eager to learn are fun.
Diane Muckenhirn has been a preceptor for several
nurse practitioner students from various Minnesota
schools of nursing. She has found that the visit time
required to see patients may need to be extended to
allow the teaching experience to be most effective.
This means that potentially fewer patients will be
seen. Most patients are willing to see a student,
especially knowing that they are also being evaluated
directly or in consultation with the health
professional. It is important that patients understand
they need not “feel bad” if they do not agree to see a
student. Muckenhirn’s experience has been that eight
in 10 patients agree to a student visit. “It keeps me on
my toes. When I have a student I must be as up-todate as they are. Students also share what they have
been learning and their energy is great!”
In nursing programs it is often up to the student to locate
their own preceptor. Muckenhirn says, “This is a
marketing opportunity. Clinics and hospitals in rural
Minnesota can notify colleges of their interest in
precepting. These preceptor sites help develop high quality
rural health care providers.”
Benefits to the students, health professionals and
the community
Dr. Goeb now serves as a preceptor in both ROE and
RPAP. Gateway Clinic has had four and five students at a
time at the various sites working with different physicians.
Dr. Goeb is one of the primary preceptors, but other
doctors take part by offering a rotation in a specialty such
as surgery or urology, or extra opportunities in obstetrics.
At Gateway, RPAP students have their own office and
computer so they are not with the doctor every minute of
every day. As skills develop, students see patients on their
own. The student discusses the encounter with Dr. Goeb
and then they both return to the patient. Students are able
to spend longer periods of time with patients than
physicians usually can. Dr. Goeb reports that students will
say something like “after we’d been talking a while [the
patient] said she has shortness of breath while climbing the
stairs.” This is more than might have come out in a visit
for an unrelated matter.
Iverson says, “I think our patients enjoy working with the
students for the most part. We have been doing this long
enough that most of our patients are used to seeing a
student pharmacist. In fact I often get unsolicited reports
back from some of my patients on how the student did in
their interaction with the patient.”
“I never felt that I could be an effective teacher, especially
when I was asked to be a preceptor in the Duluth
Residency Program only one year out of residency myself.
But I was amazed at how much I knew, how much I’d
learned, and how much I had to offer those coming up
behind us,” reflected Dr. Goeb.
“Working with nursing students really gives me a sense of
wholeness in my career,” says Muckenhirn. “I was given
time and commitment by a preceptor years ago that I
remain thankful for. I am now giving back by assisting in
the education of new nurse practitioners and the delivery
of quality care. Just last week I received an email from one
of my students thanking me for the preceptor opportunity,
telling me how much she valued her experience and
sharing that she passed her board exam and was hired in a
rural setting.”
Iverson sums up precepting like this, “If you are excited
about what you do in your practice and want to share that
excitement and knowledge, precepting is a very rewarding
experience. Just be prepared to put some time into
working with students, in planning what you want them
to learn and in evaluating their performance.”
7
Minnesota’s Loan Forgiveness Program (continued from page 3)
Mark Schoenbaum, Director
Mary Ann Radigan, Editor
Cirrie Byrnes,
Editorial Assistant
To learn more about the
Office of Rural Health &
Primary Care programs, visit
our Web site:
www.health.state.mn.us/divs/ch
s/orh_home.htm.
This information will be made
available in alternative format –
large print, Braille, or audio
tape – upon request.
• The average debt carried by health care practitioners can be staggering. The preliminary,
average educational debt for survey respondents was $99,700 for rural physicians, $39,000
for advanced practice nurses and midlevel practitioners, $31,000 for allied health and
nursing faculty, and $15,000 for nurses who agree to practice in nursing homes or ICFMR.
The Minnesota Department of Health-Office of Rural Health and Primary Care, which
administers the program, will make a final report on the evaluation available in April 2007.
Information about all state and federally-funded loan repayment and loan forgiveness programs
administered by the Minnesota Department of Health can be found at
http://www.health.state.mn.us/divs/cfh/orhpc/loan/home.htm or by calling Doug Benson at
(651) 201-3842.
Doug Benson supervises the ORHPC financial and technical assistance programs. Katherine
Cairns is the principal of Summit Health Group, an evaluation consulting group.
Printed on recycled paper with a
minimum of 20% post-consumer waste.
Attend the
Minnesota Rural Health
Conference
June 18-19 in Duluth
Information online at:
www.health.state.mn.us/divs/cfh/orhpc/conf/07.htm
85 E. 7th Place, Suite 220
P.O. Box 64882
Saint Paul, Minnesota 55164-0882
The ORHPC Quarterly is using
electronic distribution instead
of the mail. Subscribe at
http://www.health.state.mn.us/su
bscribe.html
or request other arrangements by
contacting Cirrie Byrnes at
[email protected]
or (651) 201-3844.