Un-Tapped Resources: Understanding Arizona 3RNet

Presented by:
Center for Rural Health UA MEZCOPH
Thursday, March 31, 2016 | 3:30 PM – 4:30 PM
Discussion Points
Describe 3RNet
Review how to sign-up, utilize, and improve postings
Showcase upcoming national/state website improvements
Invite open discussion: Questions | TA Needs | Other
What is 3RNet?
Purpose: A free, national online rural recruitment and retention tool
Az3RNet = Arizona Rural Recruitment and Retention Network
Arizona 3RNet Partnership
RECRUITMENT and RETENTION
Partner Key Role
SORH | Arizona Center for Rural Health Oversees management of website
PCO | ADHS/ Bureau of Health Systems Development
Manages Arizona’s workforce programs
PCA | Arizona Alliance for Community Health Centers
Recruits/retains workforce at Arizona’s FQHCs
Current National 3RNet Website
Current Arizona 3RNet Website
Free service
Number of postings are unlimited – must be healthcare related
Resources available to assist you/your organization
Types of Opportunities Sought
Process for Candidate Registration
Steps to Sign Up
Visit the Az3RNet website https://www.3rnet.org/locations/arizona
On the upper right hand side of the screen click on Employer Registration
Complete the Employer Registration form and submit
Approval provided by AzCRH to post job openings
Types of Registered Employers
Community Health Centers Critical Access Hospitals Other Rural Hospitals Medical Practices Behavioral Health Organizations Rural Health Clinics
County Government Tribal Entities Veterans Administration Medical School Associations Other
Registered Facilities by Year
2013 18 2014 32 2015 38 2016 (Jan-Mar) 7
Example - AZ Opportunity Search
Tips for Effective Site Listings Physician - Internal Medicine | URGENT NEED FOR Internal Medicine
Physician in Some City, State. J1 Waiver/H1b/National Interest Waiver approved site.. SEND RESUME IMMEDIATELY TO: [email protected]
Physician - Pediatrics | Staff Physician (Pediatrician) opportunity available at the Gold Village Health Centers in Some City, Some State. Applicant must have a medical degree or equivalent and completion of residency in Pediatrics. Must also have or be eligible for State medical license, along with a BC/BE in Pediatrics. If interested, mail résumé to:
Nurse Practitioner (NP) - Family Medicine | Mid level practitioner needed for a long standing Rural Health Clinic in Some City, Some State.
Physician - Internal Medicine | Board Eligible Internal Medicine Physician: Provides health care services to patients. This opportunity will allow you to work collaboratively with a multi-disciplinary team of professionals not only addressing the treatment of disease, but focusing on the healing process, prevention of illness, and optimal wellness of patients.
Physician - Obstetrics & Gynecology | FQHC with 40 years of Commitment and Success Diamond FQHC Values are Advocacy, Access, Respect, Efficiency, Innovation & Excellence. Join our premier organization to help ensure access to high quality, culturally responsive and comprehensive Primary healthcare to all in our communities.
Additional Ideas to Improve Postings
Solicit quotes from recently placed providers from region
Post photos of newly hired practitioners from region
Highlight communities/facilities on region page with text, photos, etc.
What ideas do you have? What has worked best for your organization?
Proposed “New” National 3RNet Website
Proposed “New” State Page
Ana Lyn Roscetti, MPH Workforce Section Manager
Lourdes Paez Workforce Development Programs
520.626.2432 [email protected]
The other 4 year Degree Building a Skilled Workforce
for the 21st Century An Equal Opportunity Employer/Program
Auxiliary Aids and Services available upon request to individuals with disabilities
Presentation Overview:
Collaboration with Workforce Innovation Opportunity Act (WIOA)
Setting Up an Apprenticeship Program
What is Apprenticeship?
IT’S EMPLOYMENT…
Combines on-the-job training (OJT) & related training instruction (RTI)
Progressive pay scale Supervised by qualified mentors Occupation Specific: 1 - 6 years in length Nationally Recognized Credential Time-tested training system
Programs can be established in many industries, including:
Various Industries:
Apprenticeship Benefits to Business Attracts Focused
Applicants Identifies
Apprenticeship – Local Workforce Area Benefits-Youth
Apprenticeship participation results in placement of youth in employment at the conclusion of training
Apprenticeship meets the definition of attainment of degree or certificate – completion rate
Setting up a Program
Standards are Registered
Apprenticeship programs can track:
How many entered employment Retention Earnings Educational attainments Exit wage data
Eligible Training Provider List (ETPL)
Registered Apprenticeship programs are automatically approved on the ETPL.
They only need to register their information. This enables jobseekers to apply for an
Individual Training Allowance (ITA) Veterans can spend their GI Bill in a
registered apprenticeship program
Registered Apprentices in Arizona 2690
Registered Programs in Arizona 121
Traditional Occupations 68
RELATIONSHIPS
Arizona Alliance for Community Health Centers at the 2016 Arizona Recruitment & Retention Conference March 31, 2016.
Randy D. Danielsen, PhD, PA, DFAAPA Dean & Professor
Arizona School of Health Sciences A.T. Still University
Mesa, Arizona
HISTORY OF PA’S
Arose in the late 1960s / early 1970s in response to primary care physician shortages in impoverished areas
PA training based on shortened MD training during WWII
Numbers began to increase dramatically when practices were allowed to bill for their services
PAs now practice in almost every medical specialty and in every state
PAs are typically paid 50 – 60% of MD/DO salary, but can bill for 85 – 100% for services provided
2
Charles Hudson Doctor Assistant
Loretta Ford RN and Henry Silver Pediatric Nurse Practioner
John Kirklin Surgeon’s Assistant
Hu C. Myers PA Baccalaureate Program
Richard Smith MEDEX
PA’S: A WORKFORCE POLICY SUCCESS IN THE U.S.
Over the past 50 years, the PA concept has been shown to be a remarkable workforce policy success: Prescribing in all states
Reimbursement through all third-party payers
High demand in the medical marketplace
Utilization and new roles are expanding
Patients accept PAs; a poll showed that 66% of citizens recognize the PA role and one-third have been treated by a PA (AAPA, 2007)
The career is attractive with high levels of job satisfaction — mean salary is $93,000/year. High levels of job and career satisfaction among PAs. Why is this?
One obvious factor: PAs complement physician practices and do not threaten physician roles or authority
The PA concept is spreading globally with programs now in Canada, England, Scotland, Australia, Saudi Arabia, Ghana, and the Netherlands
PAs have shown remarkable clinical mobility across medical specialties and settings
Hooker, RS, Cawley, JF, Asprey, DP. Physician Assistants: Practice and Policy, 3rd Edition. Philadelphia: FA Davis, 2010.
TODAY
“The PA is a competency-based occupation. Different PAs do different work. It is based on a "negotiated" role between an individual physician and a PA. This makes it unique. It means PAs can do a very wide range of tasks- and can have roles that change and expand significantly over the course of a career.” – Eugene Schneller
PHYSICIAN ASSISTANTS • Each year more than 6,000 PAs are added to the U.S. health
workforce.1
• The PA workforce is projected to increase by 58% by 2020 2, 3
• By 2025 there are projected to be 125,000 PAs • Approximately 1,942 PAs practicing in Arizona
• A provider ratio of 29 per 100,000 population
1 Demand for America’s PAs Surges in New Era of Healthcare AAPA https://www.aapa.org/twocolumn.aspx?id=3311
2 Hooker RS, Muchow, Ashley N. Supply of physician assistants: 2013- 2026. Journal of the American Academy of Physician Assistants 2014; 27:39045
3 National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care practitioners Through 2020. U.S. Department of Health and Human Services, Health Resources and Services Administration. Rockville, MD 2013
0
50
100
150
200
250
* Projected
1/4/16 there are 199 ARC-PA Accredited PA Programs in the U.S.
Chart1
1960
1960
1965
1965
1968
1968
1972
1972
1976
1976
1980
1980
1984
1984
1988
1988
1992
1992
1996
1996
2000
2000
2002
2002
2004
2004
2006
2006
2008
2008
2010
2010
2012*
2012*
2014*
2014*
2016*
2016*
2018*
2018*
1960
1965
1
1968
13
1972
59
1976
66
1980
64
1984
59
1988
53
1992
60
1996
98
1
2000
128
1
2002
131
1
2004
133
2
2006
136
6
2008
142
12
2010
156
15
2012*
164
18
2014*
180
22
2016*
182
30
2018*
184
34
PA SUPPLY PROJECTIONS According to AAPA/NCCPA figures, there are 108,000 PAs practicing in this country (2015)
10
Supply of physician assistants: 2013-2026, Roderick S. Hooker, PhD, PA; Ashley N. Muchow JAAPA Volume 27 • Number 3 • March 2014
RETIREMENT/ATTRITION/MORTALITY OF PAS
11
Supply of physician assistants: 2013-2026, Roderick S. Hooker, PhD, PA; Ashley N. Muchow JAAPA Volume 27 • Number 3 • March 2014
COMPARING NPS, PAS, AND MDS
12
NP PA MD / DO
Training 2 years part time 2 years full time 7 years minimum, full time (most do at least 8 years).
Pre-requisites BSN (+/- experience, although most do have experience)
BA or BS in any field + 1-2000 hours experience
BA or BS in any field. No experience required
Credential Traditionally MSN, moving to DNP
MS (most) MD / DO
Specialization Chosen at time of application to MSN program. Change of specialty requires additional formal training
May change fields at any time if a new employer wishes to hire the individual
Choose specialty in 4th year of training. Change of specialty requires minimum of 3 years full time additional training
Recertification None Every 6-10 years Every 10 years (most) Prescribing Yes Yes Yes Ordering Tests / Rads Yes Yes Yes Procedures If trained If trained If trained Independent? Yes in some states, no in
others No – always works with some level of physician supervision
Yes
Regulation Board of Nursing Board of Medicine Board of Medicine Salaries High 5 figures to low 6 figures High 5 figures to low 6 figures Low to high 6 figures
PA PRACTICE CHARACTERISTICS SPECIALTIES RESPONDENTS (%) Primary Care * 23.6 Surgical Subspecialties 29.1 Internal Medicine Subspecialties 10.9 Emergency Medicine 10.4 Pediatric Subspecialties 1.3 Other Specialties 24.7 Primary care include family medicine, general pediatrics, and general internal medicine
PRIMARY SETTING PRIMARY CARE ALL OTHER SPECIALTIES RESPONDENTS (%)
Physician Office/Clinic 86.4 37.9 Hospital 4.7 50.8 All Others 8.9 11.3 TYPICAL NUMBER OF PATIENTS SEEN
PRIMARY CARE ALL OTHER SPECIALTIES MEDIAN
Patients Seen Per Day 17.0 15.0 Patients Seen Per Week 75.0 60.0
American Academy of Physician Assistants. 2015 AAPA Salary Report. Accessed October 8, 2015.
PAS BY GENDER AND RACE
Gender Race
0.5
Islander 0.4
White, 86.8
Other 3.3
PA PRESCRIBING
Prescribe excluding controlled substances
Florida just passed legislation to allow PAs to prescribe controlled substances
1. “Licensure” as the regulatory term 2. Scope of practice determined at the practice site 3. Adaptable supervision requirements 4. Full prescriptive authority 5. Chart co-signature requirements determined at the
practice 6. Number of PAs a physician may supervise
determined at practice level
Source: American Academy of Physician Assistants: State Law Issues: Issue brief. 2011
ISSUE: MORE PATIENTS IN THE SYSTEM
Affordable Care Act of 2010 means:
Millions of new patients will have insurance and therefore, access to care
Increased funding for 15,000 new providers at CHC’s
Increased funding for PA /Physician training (Title VII)
PAs are seen as key players
17
ISSUE: IMPENDING PHYSICIAN SHORTAGE According to the AAMC and other health policy
experts: Shortage of 159,000 physicians by 2025 2014 Match Results for US Medical Graduates:
45 % Family Medicine filled with US graduates >90 % Derm, Ortho, ENT, Plastics, Radiation
Oncology filled with US graduates Only 2% of IM residents going into general internal
medicine practice!
ISSUE: AMERICA’S HEALTH CARE WORKFORCE
800,000 physicians currently practicing Only 1/3 of the U.S. physicians practice
primary care The number of young physicians indicating
an interest in primary care is static There are approximately 140,000 nurse
practitioners (NPs) and 108,000 physician assistants (PAs) practicing in the United States (2015)
19
ISSUE: ACCESS TO PRIMARY CARE Access to primary care is difficult for many
people living in rural America1
Growing number of rural residents who gained health insurance under the ACA will exacerbate the access problem2
Newly acquired ACA-insured population is estimated to increase the use of physicians by 7.9%3
Who will provide the additional primary care visits needed?
20
ISSUE: ACCESS TO PRIMARY CARE
PAs and NPs provide substantial portions of primary care visits in both rural and urban settings.
NPs-19% PAs-7% Both are well positioned to help alleviate
physician shortages, especially in rural areas. Patient ourtcomes are similar Patient satisfaction is high
21
Rural Health Research Center Policy Brief #155 March 2016
PA and NPs were used twice as often in CHCs than in private practice
Team Practice: 13% of all CHC encounters had an interprofessional (collaborative) involvement A higher percentage of visits to NPs (53%)
and PAs (54%) included documentation of health education/preventive services/counseling in the medical record compared to physicians (42%)
22
Hing, E., Hooker, R.S. Roles of Nonphysician Clinicians in Community Health Centers: United States, 2006-2008. NCHS Data Brief. Hyattsville, MD, National Center for Health Statistics, 2011
Integrating Physician Assistants into your practice involves many steps:
1. Assessing organization’s practice culture for PA fit
2. Evaluation of current and future productivity of physicians and PAs
3. Developing a formal job description
4. Creating a compensation plan (Salary, benefits, license fees, CME, membership dues, incentives)
5. Recruiting
6. Orientation/Training
7. Performance
National Professional meetings/conferences Consider staffing time, candidates
will need to obtain state license
RECRUITMENT OF PA’S
RECRUITMENT OF PA’S
current, evidence-based practice guidelines, feedback and experience
Although state laws vary regarding the extent of practice and level of supervision for PAs, hospitals and physician groups may independently set their own standards for supervision
26
SHAPING GREAT PHYSICIAN-PA TEAMS
Great Physician-PA teams were featured in an earlier NCCPA Foundation study (and featured in an award winning documentary) which reported five key success factors in shaping good teams!
27Source: http://www.paexcellence.org/programs/programs_best_practices.html
28
PA SUPERVISION/COLLABORATION --TYPES
• Writing and reviewing the assessment and treatment guidelines • Establishing when and under what circumstances physician
intervention is required
Concurrent supervision
• Reviewing patients on a real-time basis based on departmental guidelines or ad hoc
Retrospective supervision
RECOMMENDATIONS
PA workforce capacity can help meet the burgeoning demand for primary care
1. Expand PA training sites which will enhance the likelihood of practice in rural areas after graduation
2. Consider “Home Town” applicants to PA School.
3. Encourage loan repayment and forgiveness opportunities for PAs.*
4. Support payment policies that compensate equally for specific primary care services regardless of whether they are provided by an MD, DO, PA or CNP
*According to the NCCPA, 19.3% of recently certified PAs indicated that student debt influenced their decision to seek a primary care or non-primary care position
PA RESOURCES
The Preceptor’s Handbook for Supervising for Supervising Physician Assistants
http://www.jblearning.com/catalog/9780763773618/
Shortage Designations 101 Medically Undeserved Areas/Populations (MUA/Ps)
Health Professional Shortage Areas (HPSAs)
March 31, 2016
Arizona Department of Health Services
Health and Wellness for all Arizonans
Shortage Designation Program Purpose: • Designations identify areas or populations as having a shortage of
or need for dental, mental, and primary health care providers/services
Types of Federal Designations: • Medically Underserved Area (MUA) and Medically Underserved
Population (MUP) – Primary Care only
• Health Professional Shortage Area (HPSA) – Primary Care, Dental, Mental Health
Medically Underserved Areas • Federal designation that identifies areas as medically
underserved based on demographic data
• Area must be rational (similar demographics and care-seeking patterns) – follow pre-approved AZ Rational Service Area plan when possible
• Area is scored on 4 criteria: – Percentage of population below poverty level – Percentage of population 65 and over – Infant mortality rate – Primary care physicians per 1,000 population
MUAs, Continued • Each of the 4 criteria is given a score with a weighted value.
• Sum of scores = Index of Medical Underservice (IMU) – Scale from 0 to 100 – 0 = completely underserved, 100 = best served
• Any rational service area with a score equal to or less than 62.0 qualifies for MUA designation
Medically Underserved Populations • Used when area does not qualify as MUA
• Same data elements and computations as MUA – Difference = Use requested group within area as
population, rather than total resident civilian population – Often use low income (under 200% FPL) population for
MUPs
MUA/MUP Designation Process • Not a competitive process - Any individual or agency may submit a
designation request to the Bureau of Health Systems Development (HSD)
• HSD will evaluate the request and assess area – If area qualifies - HSD submits formal request to federal
Shortage Designation Branch (HRSA) – If designated, published online and in federal register
• Complete designation process can take 6 -12 months
• MUA/MUP designations currently are not required to be updated
Health Professional Shortage Areas • Health Professional Shortage Area (HPSA) designation
identifies an area or population as having a shortage of providers
• Primary Care • Dental • Mental Health
• HPSA designations are used to qualify for state and federal programs aimed at increasing primary care services to underserved areas and populations
Types of HPSAs • Geographic • Geographic with high needs (i.e. > 20% poverty) • Population (i.e. Low Income) • Facilities:
– State and Federal Correctional Facilities – Some facility types are eligible for an automatic HPSA
designation • Federally Qualified Health Centers (FQHCs) and Look-Alikes • Rural Health Clinics (RHCs) – must certify they see all regardless of
ability to pay • Indian Health Service/Tribal – done as a Native American
Population HPSA
Geographic Area • A rational service area - in Arizona we use an established
Primary Care Area plan – Based on demographics and care-seeking patterns
• Population to Provider Ratio Requirement: – 3,500:1 – Counts only MDs and DOs in primary care: family/general
practice, internal medicine, and Ob/Gyn (does not include mid-level providers)
– Does not include obligated providers (NHSC, J-1, federal commissioned officers)
Geographic Area with High Needs
• A rational service area that exhibits one of the following: – 20% or more of the population is @ 100 % of the poverty
level – Infant mortality rate is greater than 20
• Population to Provider Ratio Requirement: – 3,000:1
Population – Low Income
Population = Those below 200% FPL in rational service area
Providers = just those seeing patients on AHCCCS or a sliding fee scale
Population to Provider Ratio Requirement: 3,000:1
Excluded from Provider FTE Count • NHSC Federal Scholarship or Loan Repayment Providers
• Other Federal providers (e.g. Commissioned Officers)
• Physicians who are graduates of foreign schools who are not citizens or lawful permanent residents (including those with J-I or H1-B visas)
• Providers engaged solely in admin, research, or teaching
• Physicians involved exclusively in inpatient or ER care
• Providers full-time in correctional institutions
• Providers suspended under provisions of the Medicaid-Medicare-Anti-Fraud and Abuse Act for a period of 18 months or more
Contiguous Areas • Must show population of proposed HPSA cannot get services
in surrounding service areas
• Can rule out contiguous areas due to: • Over-utilization (>2,000:1) • Excessive Distance (> 30 minutes) • Significant socioeconomic differences • Designated as HPSA • Inaccessible for other reasons (i.e. reservation –
services only available to tribal populations)
HPSA Designation Process • ADHS Bureau of Health Systems Development gathers data
and submits applications to federal HRSA office
• HRSA analyst reviews and approves/rejects for designation
• If designated, published online and in federal register
• HPSA designations last for 3 years, at which time the area must be assessed and submitted for re-designation – HRSA currently implementing new designation application system and
process
HPSA Score • HRSA assigns each HPSA a score based on data we submit
• Max primary care score = 25 (Higher score = higher need)
• All clinics/providers in a HPSA have same HPSA score and identification number
• Primary care HPSA score based on 4 categories: – Population to provider ratio – % population with incomes below FPL – Infant Health Index – Travel distance/time to nearest source of accessible care outside of HPSA
Area vs. Facility HPSAs Area (geo or pop) HPSAs: • Community-based (must follow AZ Primary Care Area boundaries) • Must meet specific criteria regarding population-to-provider ratio • Must eliminate all contiguous areas as potential sources of care • Must be updated regularly
Auto Facility HPSAs: • Only applies to that facility (and satellites in the case of FQHCs) • No ratio or contiguous area requirements for designation • Currently no requirement to update (scores may be reassessed upon
request)
HPSAs and Workforce Programs HPSA designation is an eligibility requirement for: • National Health Service Corps (NHSC) Loan Repayment • NHSC Scholar Program • Arizona State Loan Repayment • J-1 Visa Waiver Program
May use area or facility HPSA score when applying for these programs – use whichever is higher. • Note that NHSC “Freezes” HPSA scores in their system on January
1 of each year (i.e. takes a snapshot of HPSAs on 1/1 and uses those throughout LRP cycle)
Rural Health Clinics
• RHCs are eligible for facility HPSA only if they provide access to care regardless of ability to pay (including sliding fee scale)
• To obtain facility HPSA, RHCs must submit a Certificate of Eligibility form to HRSA (contact Tracy Lenartz for electronic copy of form)
IHS/Tribal Facilities
• Automatic Native American Population HPSA – designation for each facility
• ADHS collaborated with OSD/HRSA to re-score IHS and tribal facilities in 2010/2011
• While scores are fairly recent, please do contact us if your facility has experienced a significant change (i.e. provider turn-over) that could impact your score.
FQHCs and FQHC-LA
• ADHS collaborated with OSD/HRSA to re-score FQHC and LA facilities in 2012/2013 and in process to reassess again now
• Significant increase in facility scores across the state resulted from this effort
• Goal: ensure scoring is consistent and fair across AZ, and competitive nationally for NHSC
• While scores are fairly recent, please do contact us if your facility has experienced a significant change (i.e. provider turn-over) that could impact your score.
Resources • HSD Interactive web-based mapping tool (“Designation
Mapper”) http://www.azdhs.gov/prevention/health-systems-development/shortage- designation/designation-mapper/index.php
• HPSA Searchable Database http://hpsafind.hrsa.gov/
HPSA Find Website http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx
To find area HPSAs
To find facility HPSAs
Search by County http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx
including facilities
Tip: FQHCs are listed only by parent site and county that site is located in
Search by Address http://datawarehouse.hrsa.gov/geoAdvisor/ShortageDesignationAdvisor.aspx
Note that this will NOT give you Facility HPSAs – only Area HPSAs
Address Search - Example
Contact Info
Any Questions?
Thank You
STAR² Center Consultant
for Recruitment and Retention www.chcworkforce.org
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2016 Training •Hot TopicsMonthly Webinar
Series
Primary Care Clinicians
Staffing for Team Based
Resources • Peer
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Go Online •Review Your Profile & User Guide •Complete Self-Assessment Tool
Call Us •Schedule Call for Profile Review •Request TA from Workforce Expert
• 800-787-2512 • [email protected]
Michelle Varcho
• 844-ACU-HIRE • [email protected]
Incentives for
Ana Roscetti, MPH Workforce Section Manager
Public Health Prevention Services Division of Public Health Services l Arizona Department of Health Services
Workforce Programs Objectives
• To improve the accessibility of health care for underserved areas and populations in Arizona
• To incentivize primary medical, dental, and mental health who agree to serve in medically underserved areas by providing loan repayment incentives or in-kind support
• To encourage retention of healthcare professionals in areas of need
• National Health Service Corps (NHSC) Loan Repayment Program
• Arizona Loan Repayment Programs (SLRP)
–Public or Non-profit –Rural, Private Practice
Workforce Programs
Arizona Loan Repayment Programs
• Administered by the Arizona Department of Health Services (ADHS), Arizona Primary Care Office (PCO)
• Provides loan repayment in exchange for an initial two year commitment in a Health Professional Shortage Area (HPSA) or an Arizona Medically Underserved Area (AzMUA) of the State
• Available to providers employed by a public or private non-profit or rural private practices located in a HPSA or an AzMUA
• A.R.S. 36-2172 and A.R.S. 36-2174 are the statutes that govern the programs.
Arizona State Loan Repayment Programs (SLRP)
Program Updates in 2015:
• Governor Doug Ducey signed Senate Bill 1194 into law on Feb. 24, 2015. This bill became effective July 3, 2015
• Enhances SLRP through 3 key changes: • Expands the eligible disciplines • Enhances the award amounts • Extends the years of participation
• The law requires the program to prioritize providers who are residents of Arizona, providers in rural areas and those in areas with high Health Professional Shortage Area (HPSA) scores in Arizona.
• The law provides eligibility for part-time providers and those providing services via telemedicine.
• The law provides for an exempt rulemaking until December 31, 2016.
• No additional appropriation resulting from the legislation.
• Program operates at a combined state/federal funding of $850,000 per year.
Categories Program Before SB 1194 Enhanced Program Effective July 3, 2015
Eligible Disciplines Physicians (Family Medicine, Dentists, OB/GYN, Pediatrics, Internal Medicine) PA, NP, Nurse Midwives
Physicians (Family Medicine, OB/GYN, Pediatrics, Internal Medicine, Geriatrics, Psychiatry), Dentists PA, NP, Nurse Midwives, Behavioral Health Providers, Pharmacists
Award Amounts Up to $40,000/2 year commitment for physicians and dentists per state statute
Up to $15,000/2 year commitment for Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives per state statute
Up to $65,000/2 year commitment for physicians and dentists
Up to $50,000/2 year commitment for advanced practice practitioners
Priority consideration given to providers in rural underserved areas, high HPSA score areas, and those who are residents of Arizona.
Service Years Capped to 4 years per state statute No cap as long as provider continues to have qualifying loans.
Enhanced Arizona Loan Repayment Programs - At-A-Glance
Eligible disciplines:
Key Requirements for Providers and Service Sites:
• Employed and serving in a public, private non-profit or rural private practice site • Located in a federally designated HPSA or AzMUA (rural private providers) • Serve everyone regardless of ability to pay or source of payment • Accept AHCCCS and Medicare • Accept qualifying health plan assignment (NEW) • Implement a Sliding Fee Scale for uninured or low income persons at or below
200% of the Federal Poverty Level Guidelines
Program Priorities since SB 1194
• Revise the program administrative rules – Final draft rules posted for a 30 day public comment period from February 19,
2016 till March 22, 2016 – Final draft rules effective April 1, 2016
• Revise the program website including program marketing materials and application forms – Ready to launch by April 1st, 2016
• Increase program funding to support recruitment and retention – Request for supplemental funding from HRSA – Identify funding partners
Arizona Loan Repayment Programs
Impact of SB1194
8%
43%
10%
15%
18%
6%
Employer/Site
Actual Applications Received (Historical and Current)
0
2
4
6
8
10
12
14
16
18
SB 1194
CONTRACTED PROVIDERS
Physicians 10 19 23
Dentists 3 7 11
Pharmacists N/A N/A 2
* FY 2016: Federal ($200,000) + EMS (650,000) + AMSLP (195,800) = $1,045,800
Programmatic Rules Changes Effective April 1, 2016
1. R9-15-201. Qualifying Loans and Restrictions 2. R9-15-202. Primary Care Provider and Service Site Requirements 3. R9-15-203. Initial Application 4. R9-15-204. Supplemental Initial Application 5. R9-15-205. Renewal Application 6. R9-15-205.01 Renewal Application Restrictions 7. R9-15-206. Time-Frames 8. R9-15-207. Primary Care Provider Health Service Priority 9. R9-15-208. Rural Private Primary Care Provider Health Service Priority 10. R9-15-209. Allocation of Loan Repayment Funds 11. R9-15-210. Verification of Primary Care Services and Disbursement of Loan Repayment Funds 12. R9-15-211. Request for Change 13. R9-15-212. Contract Suspension 14. R9-15-213. Liquidated Damages for Failure to Complete the Terms of the Contract 15. R9-15-214. Waiver of Liquidated Damages 16. R9-15-215. Contract Cancellation
R9-15-207. Primary Care Provider Health Service Priority (New Prioritization)
• Requires the determination of health service priority for each new or renewal application. • Clarifies the health service priority scoring method for providers working at multiple sites:
– Uses the health service priority score of the primary site. Primary site is defined as the service site where the provider spends more than half of his full-time or half-time hours.
– If there is not a primary site, use the average of the total health service priority score for each site.
• Provides the scoring factors to use when determining the applicant’s health service priority score.
• Clarifies the highest HPSA to use for a specific provider type • Provides the method for breaking a tie when more than 1 provider have the same health
service priority score and: – Only one provider from the same service site or employer can be awarded due to the
award cap per year; or – Only one provider can be awarded due to funding limitation;
Current Prioritization Methodology (Maximum Points = 26) 1. Location of service site
– Rural = 4 – Non Rural = 0
2. Degree of Shortage Ranking – DOS 1 = 4 – DOS 2 = 3 – DOS 3 = 2 – DOS 4 = 1
3. Population to Provider Ratio Points – 0 to 10 points
4. Percentage of minority populations in the primary care area – >50% = 4 – 40 - 50% = 3 – 30 - 39% = 2 – 20 - 29% = 1 – <20% = 0
5. Distance of the site to next nearest town with a population of 20,000 or greater – >45 miles = 4 – <45 miles = 0
Priority 1 = 18 - 26 points (100% funding) Priority 2 = 9 - 17 points (90% funding) Priority 3 = 0 - 8 points (80% funding)
The total health service priority score will be obtained for each new or renewal application based on points obtained from the following factors:
1. Whether the service site is located in a rural area Yes = 10 points No = 0 points
2. Service site’s highest HPSA score as applicable to the applicant’s discipline 3. Percentage of the service site’s total patient encounters that are underserved (total of encounters on
Medicaid (AHCCCS), Medicare, Sliding Fee Scale, or free of charge) Greater than 50% = 10 points 35-50% = 8 points 26-34% = 6 points 11-25% = 4 points Less than 10% = 2 points
4. Whether the distance of the service site to the next nearest Sliding Fee Scale clinic providing similar type service as the applicant is greater than or equal to 25 miles
Greater than 25 miles = 4 points Less than 25 miles = 0
Arizona State Loan Repayment Programs (SLRP) R9-15-207. Primary Care Provider Health Service Priority (New Prioritization) Maximum Points = 71
5. For the initial application, whether the applicant is newly employed at the service site or by the employer (Newly employed as defined in A.A.C. R9-15-201)
Yes = 2 points No = 0 points
6. Whether the applicant is providing services with a patient on-site Yes = 4 points No = 0 points
7. Whether the applicant is a resident of Arizona per A.R.S. 15-1802 (hyperlink to http://www.azleg.gov/ars/15/01802.htm)
8. Whether the applicant is a graduate of an Arizona graduate educational institution Yes = 4 points No = 0 points
9. Whether the applicant has experience in serving the medically underserved as defined in A.A.C. R9- 15-201)
10. Whether the applicant is providing services full-time or half-time Yes = 3 points No = 0 points
Arizona State Loan Repayment Programs (SLRP) R9-15-207. Primary Care Provider Health Service Priority (New Prioritization)
R9-15-209. Allocation of Loan Repayment Funds • Allocation of funds for approved new or renewal applications will be based on descending health service
priority score. • Award amounts are based on the service site’s HPSA score. • Order of allocation:
1. 3rd year renewals in HPSA 14 and above (April allocation process); 2. Initial applications (June allocation process);
• New initial application awards are capped to 2 per site per year to a total maximum of 4 per employer per year.
3. Other renewals (October allocation process) • Initial applications denied during the calendar year due to the annual award cap per site or per
employer • Previously denied application • Renewals after 3rd year regardless of HPSA • Renewals after the initial contract for those in HPSA below 14 • Resuming participation after a contract lapse.
• Approved renewals with a period lapse will be allocated an amount for the contract year succeeding the last participation year.
• Provides the policy for donated funds and the Department’s process for administering donated funds
Contract Year of Service Maximum Annual Amount for Full-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13
Initial two years $65,000 $58,500 $52,000 Third year $35,000 $31,500 $28,000 Fourth year $25,000 $22,500 $20,000
Fifth year and continuing $15,000 $13,500 $12,000
Contract Year of Service Maximum Annual Amount for Part-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13
Initial two years $32,500 $29,250 $26,000 Third year $17,500 $15,750 $14,000 Fourth year $12,500 $11,250 $10,000
R9-15-209. Allocation of Loan Repayment Funds
Payment Structure for Physicians and Dentists
Contract Year of Service
Advance Practice Providers, Behavioral Health Providers and
Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13
Initial two years $50,000 $45,000 $40,000
Third year $25,000 $22,500 $20,000
Fourth year $20,000 $18,000 $16,000
Contract Year of Service Maximum Annual Amount for Part -Time
Advance Practice Providers, Behavioral Health Providers and Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13
Initial two years $25,000 $22,500 $20,000
Third year $12,500 $11,250 $10,000
Fourth year $10,000 $9,000 $8,000
Arizona State Loan Repayment Programs (SLRP) R9-15-209. Allocation of Loan Repayment Funds
Payment Structure for Other Provider Types
Health Service Priority Points Applicant Ranking HPSA Score Discipline Amount Eligible*
70 1 16 MD $58,500
69 2 21 DDS $65,000
67 3 14 NP $45,000
63 4 18 PA $50,000
60 5 20 MD $65,000
58 6 15 MD $58,500
55 7 21 NP $50,000
54 8 16 PharmD $45,000
53 9 18 LCSW $50,000
52 10 21 DDS $65,000
52 10 21 Pharm D $50,000
* Or up to the applicant’s total student loan indebtedness
EXAMPLE
For more information Arizona State Loan Repayment Programs
An opportunity to pay off student loans while providing care to communities in need
National Health Service Corps Loan Repayment Program (NHSC LRP)
An opportunity to pay off student loans while providing care to communities in need
Bureau of clinician recruitment and service • The NHSC is part of HRSA’s Bureau
of Clinician Recruitment and Service (BCRS)
• BCRS coordinates the recruitment and retention of health professionals to work in medically underserved communities
Department of Health and Human Services
(HHS)
(HRSA)
BCRS chart
NHSC SP
NHSC LRP
NHSC S2S
National Health Service Corps Student to Service Loan Repayment Pilot Program
NHSC SLRP State Loan
• Recruits fully-trained health professionals to provide culturally competent, interdisciplinary primary health care services to underserved populations located in selected Health Professional Shortage Areas (HPSAs)
• Assists clinicians in repayment of qualifying educational loans that are still owed in exchange for service in a HPSA
National Health Service Corps Loan Repayment Program
Key Updates • ACA-related funding for NHSC expired on Sept. 30, 2015. NHSC funding
reverts back to base funding. • In FY 2014, Arizona received 5th highest allocation for NHSC LRP funding at
$6.84 million (NY, CA, IL, MO, AZ). – New awards - $5.48 Million
• 59% approval rate for new applications • 67% approval rate for new applications at HPSA score 14 and
above. – Continuation - $1.36 Million
• 100% approval rate for continuation applications. • Total NHSC LRP participants in AZ: 379 • Total NHSC certified sites in AZ: 971
NHSC Field Strength - National Data
26% Physicians
18%Physician Assistants
Providers
More than 9,200 NHSC primary care providers serving at nearly 5,000 sites.
National Health Service Corps (NHSC) Loan Repayment
MD/DO, 33%
Dentist, 13%
RDH, 2%
NP, 26%
PA, 9%
Must be licensed in one of the following:
ELIGIBLE DISCIPLINES
• Physician (MD or DO) • Nurse practitioner • Certified nurse-midwife • Physician assistant • Dentist (general or pediatric) • Dental hygienist • Psychiatrist • Licensed clinical psychologist • Licensed clinical social worker • Psychiatric nurse specialist • Marriage and family therapist • Licensed professional counselor
Must meet the following requirements: • US Citizen or National • Current AZ license • Have unpaid government or commercial
loans for school tuition, reasonable educational and living expenses, segregated from all other debts (that is, not consolidated with non-educational loans)
• Currently work or ready to work in a NHSC- approved facility located in a Health Professional Shortage Area
National Health Service Corps (NHSC) Loan Repayment Provider Eligibility
How do providers benefit from NHSC LRP? Service
By joining the thousands of NHSC participants across the country, you have an opportunity to provide primary health care services to communities in need
Eligible Service: Part Time or Full-Time, Primary Care Outpatient Services, Inpatient Services at Critical Access Hospitals, Telemedicine, Teaching, Minimal Administrative
Ineligible Service: Inpatient Services except CAH, Home Health
Loan Repayment • Funds to repay outstanding qualifying educational loans
• Funds are exempt from federal income and employment taxes
• Funds are not included as wages when determining Social Security benefits
An opportunity to be part of something bigger
than yourself
How do providers benefit from NHSC LRP?
Program options:
• Full time: 40 hours per week for a minimum of 45 weeks per year • Part time: 20 hours per for a minimum of 45 weeks per year
Additional Loan Repayment Awards:
Continue loan repayment beyond the initial contract, one year at a time, and pay off all qualifying educational loans
Must meet the following eligibility requirements:
• Located in a designated HPSA • Accept Medicare and Medicaid • Use Sliding Fee Scale • Non-discriminatory policy in the provision of health
services • Has capacity to maintain a competitive salary, benefits,
and malpractice coverage package for clinicians • Must receive NHSC certification
Eligible Sites
• Federally Qualified Health Center or Look-Alike (FQHC or FQHC-LA)
• Certified Rural Health Clinic (RHC) • Indian Health Service Site (Federal or Tribal) • Solo or Group Partnership or Practice • Hospital-Affiliated Primary Care Practice • Critical Access Hospital • Managed Care Network • State or Federal Prison • U.S. Immigration, Customs and Enforcement Site • Public Health Department • Other Health Clinics
National Health Service Corps (NHSC) Loan Repayment Service Site Eligibility
Key Updates
• Application cycle is open for NHSC Loan Repayment Program through April 5, 2016 7:30 pm ET.
• NHSC Site Application Cycle is set to open on April 12, 2016.
• Total NHSC participants in AZ: 351 – LRP: 328 – SP: 22 – S2S: 1
• Total unique NHSC certified sites in AZ (March 2016): 430
Other Updates • HPSA score effective January 1, 2016 will be used for the prioritization funding.
• Providers in residency programs with a provisional license may apply; however, they must possess a current, full, permanent, unencumbered, unrestricted health professional license before accepting an NHSC LRP award.
• Behavioral & Mental Health Providers: At least 32 hours/week or the full-time hours must be spent for providing patient care at the approved service site(s) previously 21 hours of the 40 hours per week.
• Primary Care Behavioral and Mental Health providers must practice in a community based setting that provides access to comprehensive mental and behavioral health services. Participants who are providing services in a private practice (either solo or group practice) will only be allowed to fulfill their NHSC service obligation if it can be demonstrated that the practice is formally affiliated with a comprehensive community based facility.
• Definition: Comprehensive Community Based Primary Behavioral and Mental Health Setting or Facility- For the purposes of the National Health Service Corps, this is a site that provides comprehensive primary behavioral and mental health care services, which may include but is not limited to: screening and assessment, diagnosis, treatment plans, therapeutic services including access to medication prescribing and management, crisis care including 24 hour call access, consultative services, care coordination, and case management. Sites must function as part of a system of care to ensure continuity of patient-centered, comprehensive, and coordinated care. The site must offer or ensure access to ancillary, inpatient, and specialty referrals.
Other Updates - Continuation
NHSC Site Certification Process • NHSC Site Application Cycle set to open on 4/12/16 • Sign up to receive notice:
https://public.govdelivery.com/accounts/USHHSHRSA/subscriber/new?topic_id=USHHSHRSA_134 • Review the NHSC Site Reference Guide • http://nhsc.hrsa.gov/downloads/sitereference.pdf • Prepare supporting documents
– Policies on Non-Discrimination of patients based upon race, color, sex, national origin, disability, religion, age, or sexual orientation
– Sliding Fee Schedule (SFS) Documents • SFS Table based on current Federal Poverty Level Guidelines • SFS Policies and Procedures • SFS Financial Assistance Worksheet • SFS Signage • Proof of Referral to Ancillary, Inpatient and Specialty Care • NHSC Site Data Table (12 month data required)
• Apply online and apply early
NHSC Job Center
Learn more at http://www.nhsc.hrsa.gov/loanrepayment/index.html
Nurse Corps Loan Repayment Program
• Administered by the Bureau of Healthcare Workforce (BHW) in the Health Resources Services Administration (HRSA) of the US Department of Health and Human Services (DHHS).
• Aims to alleviate the shortage of nurses across the country by offering loan repayment assistance to registered nurses and advanced practice registered nurses, such as nurse practitioners, working in a public or private nonprofit Critical Shortage Facility OR nurse faculty employed by an accredited school of nursing.
– Critical Shortage Facility - a health care facility located in, designated as, or serving a primary medical care or mental Health Professional Shortage Area (HPSA).
• Repayment of 60 percent of the total outstanding qualifying educational loan balance incurred while pursuing an education in nursing in exchange for a 2-year service commitment.
• Qualifying participants may receive an additional 25 percent of their original loan balance for a third year of service.
Eligibility Requirements: • RNs or Advanced Practice Registered Nurses i.e. Nurse Practitioners • U.S. citizen, U.S. national, or lawful permanent resident • Current license to practice as an RN and received a diploma, associate’s,
bachelor’s, master’s, or doctoral degree in nursing • Full time employment (at least 32 hours per week) at a public or private
nonprofit Critical Shortage Facility OR employed full time at an accredited, public or private nonprofit school of nursing;
• Completed the education program for which the loan applies.
Service Site Eligibility Requirements: • Nurse Faculty: Accredited, public or private nonprofit school of nursing • Registered Nurses and Advanced Practice Registered Nurses: Public or private nonprofit
Critical Shortage Facility: – Critical Access Hospital – Disproportionate Share Hospital – Public Hospital – Federally Qualified Health Center – Indian Health Service Health Center – Native Hawaiian Health Center – Rural Health Clinic – Skilled Nursing Facility – State or Local Public Health or Human Services Department – Ambulatory Surgical Center – Home Health Agency – Hospice Program – Non-Disproportionate Share Hospital – Nursing Home
Funding Preference: • Registered Nurses and Advanced Practice Registered Nurses:
– Nurses with the greatest financial need (those with debt to salary ratio of 20 percent or greater)
– Mental Health or Primary Care Health Professional Shortage Area (HPSA) score.
• Nurse Faculty: – Nurse faculty with the greatest financial need (with debt to salary ratio of 20 percent or
greater) – Working at schools of nursing with at least 50 percent enrollment of students from a
disadvantaged background.
Funding Tier Refactoring
Ratio CSF Primary Care or Mental Health
HPSA Score
Ratio Schools of Nursing (SON) Funding Preference
Tiers
≥100%
a disadvantage background
<100%
a disadvantage background
For more information Nurse Corps Loan Repayment Program:
Arizona J1 Visa Waiver Program
What is a J1 Visa? – Temporary, Nonimmigrant Visa – Clinical Resident or Fellow – Duration limit of seven years – Limited exclusively to Graduate Medical Education
(i.e., no moonlighting) – Mandatory, across-the-board, two-year home
residence obligation
When to employ a J1 physician? The J1 Visa Waiver Program is a last resort recruitment strategy if the employer has a significant challenge in recruiting and can demonstrate unsuccessful recruitment efforts of US-based physicians for at least 6 months or longer
RELEVANCE OF TWO-YEAR HOME RESIDENCE OBLIGATION: • Disqualifies J-1 from H-1B visa and/or permanent residence status unless:
– Obtains a waiver of obligation; or – Goes back to HOME country for two years
J-1 WAIVER OPTIONS: – Interested Governmental Agency (IGA) – State Department of Health – Exceptional Hardship – Persecution
• J1 Visa Waiver - a waiver of the two-year foreign residence requirement as it applies to foreign medical graduates (pursuant to Section 214(k) of the Immigration and Nationality Act 8 USC 1184, as amended by PL 103-416).
• The J1 Visa Waiver Program (aka Conrad State 30 Program) was created in 1994 to help rural and underserved communities across the United States in recruiting primary care providers.
• The J1 Visa Waiver Program allows foreign physicians to practice in medically-underserved communities without returning to their home residence, thus, allowing them to receive nonimmigrant, H-1B status (temporary worker in specialty occupation) for three years.
• The U.S. Citizenship and Immigration Services (USCIS) is the Federal Agency that grants J1 Visa Waivers.
• The Arizona Department of Health Services (ADHS) acts as an Interested Agency in supporting J1 Visa Waiver requests on behalf of J1 physicians willing to practice in medically underserved areas of the State.
• Thirty (30) slots are available per year (22 primary care, 7 specialist, 1 discretionary).
• Annual application cycle is from October 1 through November 30.
Provider • Have an offer of full time
employment for 40 hours per week at an eligible service site
• 3 year minimum obligation • Provide primary care or specialty
services in an approved site • AZ medical license or eligible for an
AZ medical license
Service Site • Located in a designated HPSA, MUA or MUP • Accept Medicare and Medicaid • Have a non-discriminatory policy in the
provision of health services • Use a Sliding Fee Scale • Demonstrate unsuccessful recruitment efforts
of a U.S. citizen physician for at least 6 months prior to the J1 waiver request
• Operational and providing care for at least six months as of the date of the request
Eligible disciplines: MDs in primary care discipline (internal medicine, family or general practice, pediatrics, OB/GYN or psychiatry) or specialists
Arizona National Interest Waiver Program (NIW) • The Federal National Interest Waiver (NIW) program allows certain foreign workers including
foreign physicians (MDs) with advanced degrees or exceptional abilities to work in the United States.
• The federal guidelines allow states to recommend a national interest waiver to foreign physicians.
• ADHS act as an interested agency attesting that the foreign physician’s work is in the public interest.
• ADHS will consider requests for ADHS NIW support from J1 physicians meeting the following conditions:
– Obtained a J1 waiver from USCIS based on ADHS recommendation
– Practiced at an eligible service site (within designated HPSA/MUA) for at least one year immediately preceding the request for an ADHS NIW support and will continue to practice in the same or similar setting to a total aggregate of 5 years (including J1 obligation)
– Complied with the ADHS J-1 Visa Waiver Programs policies
For more information Arizona J1 Visa Waiver Program
http://www.azdhs.gov/hsd/workforce/j-1-waiver/index.htm
REGISTER YOUR FACILITY NOW! www.3rnet.org
AZ 3RNet Program Contacts
Center for Rural Health, www.crh.arizona.edu Joyce Hospodar, MBA, MPA, Manager Health Systems Development
[email protected] , 520.626.2432 Rebecca Ruiz, Senior Program Coordinator
[email protected] , 520. 626.2243
ADHS, Bureau of Health Systems Development, www.azdhs.gov/hsd/ Ana Lyn Roscetti, MPH, Workforce Section Manager
[email protected] , 602.542.1066
[email protected] , 602.288.7550
Ana Lyn Roscetti, Workforce Section Manager Email: [email protected] Phone: (602) 542-1066
ARIZONA PRIMARY OFFICE CONTACT INFORMATION
Patricia Tarango, Bureau Chief, Health Systems Development Email: [email protected] Phone: (602) 542-1436
Tracy Lenartz, Designations Specialist/Health Planning Consultant Email: [email protected] Phone: (602) 542-1772
North Country HealthCare/ NAHEC Family Medicine Residency Program
Presentation to the 2016 Recruitment and Retention Conference
March 31, 2016
Presentation Overview
• North Country/ NAHEC Overview • Overview of need • Graduate Medical Education 101 • NC/NAHEC Family Medicine Residency Program • Why Teaching Health Centers
North Country History and Mission
• Northern Arizona AHEC- 1987 • Flagstaff Community Free Clinic- 1991 • North Country HealthCare (FQHC)- 1996
To provide accessible, affordable, comprehensive, quality primary healthcare in an atmosphere of respect, dignity
and cultural sensitivity. The health and well-being of patients and community alike are promoted through direct services, training / education,
outreach and advocacy.
(FM, IM,OB/Gyn, Peds) • Dental • Behavioral Health • Prenatal Care • Breast & Cervical Cancer
Screening • Diabetes Management
Community Health
Prenatal & Well Child Programs
Health Professions Student Education and Training
Medical Education
Community Health Education
• State population 6,553,255
Arizona Physician Supply
• Active physicians per 100K pop in 2012 Arizona 230.9 (rank 32/50 states) State median 244.5
Active primary care physicians per 100K pop in 2012 Arizona 72.1 (rank 37/50 states) State median 81.5
Undergraduate Medical Education
• Students enrolled in medical school per academic year 2012-13, per 100K pop Arizona 33.1 (rank 20/50 states) State median 29.1
Medical Students and Residents
• Total students in Arizona 2170 • Total residents in Arizona 1523
• Reference 1
Graduate Medical Education
• Total Residents/Fellows in ACGME Programs per 100K pop, as of 12/31/11 Arizona 23.5 (rank 37/50 states) State median 26.8
Primary Care Residents/Fellows Arizona 9.4 (rank 33/50) State median 10.4
Retention of Physicians
• Percent of Physicians Retained in State from UME in 2012
Arizona 43.2% (rank 19/50 states) State median 38.7%
Percent of Physicians Retained in State from GME in 2012
Arizona 48.4% (rank 16/50 states) State median 44.9%
Retention
• Percent of Physicians Retained in State from UME and GME Combined, in 2012 Arizona 74.2% (rank 12/50 states) State median 68.1%
Reference 1
Increased Demand for Physicians
• Growing population of all ages • Growing population of older people, with
more health issues • Better access to health insurance with the
Affordable Care Act • Renewed emphasis on primary care as part of
a cost-effective health care system
Physicians Needed to Meet US Rate per 100,000
• Active primary care physicians in Arizona: Current supply: 5151. Rate 77.1 Target supply: 6042. Rate 90.5
Physicians needed 891
Allopathic FM Residencies and Graduates per Year
• Banner University Medical Center – Phoenix 8 • Abrazo Central Campus 7 • Honor Health Scottsdale – Osborn 8 • Dignity Health St. Joseph’s 8 • UofA Tucson 8 • UofA South Campus 8 • Yuma Regional Medical Center 6 • Total 54
• Reference 3
Osteopathic FM Residencies and Graduates per Year
• Kingman Regional Medical Center 3 • Mountain Vista, in Mesa 4 • Canyon Vista, in Sierra Vista 2 • El Rio, Tucson 4 • Total 13 • Grand Total for All Residencies: 67
• Reference 4
Distribution of Primary Care Physicians in Arizona, 2010
• Physicians in primary care specialties: 5106 • Percent urban: 88.9% (Arizona pop 87.5%) • Percent large rural towns 6.0% (low) (AZ 6.1) • Percent small rural towns 4.0% (low) (AZ 5.0) • Percent isolated small rural towns 1.1% (low)
(AZ 1.4%)
• Reference 5, Table 1.1
Distribution of Obstetrics and Gynecology Physicians in Arizona, 2010 • Physicians in the specialty: 784 • Percent urban: 90.5% • Percent large rural towns 5.6% (low) • Percent small rural towns 3.7% (low) • Percent isolated small rural towns 0.1% (low)
• Reference 5, Table 1.1
Rural Arizonans compared to Urban Arizonans
• Older (more susceptible) • Poorer (less access to treatment) • Less healthy (less resilient)
• American Indians in Arizona have higher incidences of diabetes, heart disease, certain cancers, tuberculosis, substance abuse, obesity and violence than other racial groups
• Reference 5
Distribution of Family Medicine Physicians
• “Family medicine is the only specialty that distributes itself like the population.”
- Robert Bowman, MD
• Undergraduate Medical Education (aka medical school) vs. Graduate Medical Education (aka residency)
• ACGME (MD) vs AOA (DO) • Sponsors of programs almost exclusively hospitals
and academic medical centers • GME funding largely through CMS broken into 2
payments (Indirect and Direct) vs Teaching Health Center (HRSA)
• Accreditation process
Operations Models
THC Model
THC Model
Residency Program
(continuity clinic)
Medicare GME $
Mission of the Residency
• To extend the mission of North Country HealthCare in providing accessible, comprehensive, quality, affordable care in a primary healthcare setting across Northern Arizona.
Goals of the Residency
• Prepare a group of family physicians for autonomous practice in rural and frontier Northern Arizona.
• Prepare culturally competent physicians for the region.
Objectives
• 1. Develop family medicine residency rotations in Flagstaff, the Indian Country, and elsewhere in our Northern Arizona service area
• 2. Require rural rotations of four weeks duration during second and third years of residency. Available rotations will be in Tuba City (Navajo), Polacca (Hopi) and Whiteriver (White Mountain Apache).
ACGME
• Accreditation Council on Graduate Medical Education is the accreditation body for residencies and fellowships, and for Sponsoring Institutions
• Residency Review Committees (RRCs) within the larger ACGME
Sponsoring Institution
• North County HealthCare is the Sponsoring Institution for the family medicine residency.
• Application submitted August 2014. • ACGME granted accreditation on 11/25/14.
Responsibilities of the SI
• The Sponsoring Institution must assume ultimate responsibility for the program, including all resident assignments at all participating sites.
• SI and the program must ensure that the program director has sufficient protected time and financial support for his or her education and administrative responsibilities to the program.
• A written statement must document the SI’s commitment to GME by providing the necessary financial support for administrative, educational, and clinical resources, including personnel.
Responsibilities of the SI
• SI must identify a Designated Institutional Officer (DIO), who works in collaboration with a Graduate Medical Education Committee (GMEC).
• DIO must have authority and responsibility for the oversight and administration of SI’s ACGME accredited programs.
Academic Partnerships
• AT Still University • The University of Arizona College of Medicine:
Tucson • The University of Arizona College of Medicine:
Phoenix
• Flagstaff Medical Center • Kingman Regional Medical Center • Tuba City Regional Healthcare Corporation • Hopi Health Care • Whiteriver Indian Health Service Hospital • Little Colorado Medical Center • Winslow Indian Health Care Center • Brookdale-Flagstaff • Coconino County Health Department
Experiences and Partner Locations
• Winslow facilities: general surgery • Kingman Regional Medical Center: radiology
and emergency medicine • Brookdale-Flagstaff: longitudinal geriatrics
patients
Experiences and Partner Locations
Residency Application
• Evaluations forms derived from the curriculum • Competency areas: Patient Care, Medical
Knowledge, Communication, Professionalism, Systems Based Practice, Practice Based Learning
Next Steps
• Final application for accreditation is ready for submission to the ACGME
• RRC will arrange for a site visit over the next few weeks
• RRC site visit report becomes part of our portfolio for review
• Anticipate provisional accreditation • Inaugural class of four residents in 7/17
Why Teaching Health Centers • Meeting patient care demands (access) • Economic impact • Job creation • Increased Quality • Solid model for rural and frontier care • Attraction of faculty and residents with “the right stuff” • High quality community-based training • Health workforce solution
• Simple, its our future workforce… “Growing our Own”
Things to consider when moving from Contemplation to Action
• Shared mission • Affiliation agreements • Financial • Responsibilities and Control • Legal issues • Standards and accreditation
CONTACT INFORMATION
Profile, AAMC Center for Workforce Studies. • 2) Graduate Medical Education in Arizona. Growing the Physician Pipeline.
Arizona Health Futures. St. Luke’s Health Initiatives, March 2012. • 3) American Academy of Family Practice (AAFP) Website, Residency
Directory, accessed 9/11/15. • 4) American Osteopathic Association (AOA) Website, Approved Internships
and Residencies, accessed 9/11/15. • 5) Arizona Rural Health Workforce Trend Analysis 2007-2010, A report
prepared for the Arizona Area Health Education Centers Program, Tabor, J. and Eng, H.J., Mel and Enid Zukerman College of Public Health, The University of Arizona, June 2012.
• 6) ACGME Institutional Requirements, effective 7/1/15.
3RNet Overview 3-31-16
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Current National 3RNet Website
Current Arizona 3RNet Website
Types of Opportunities Sought
Process for Candidate Registration
Steps to Sign Up
Process for Employer Registration
Types of Registered Employers
Registered Facilities by Year
Example - AZ Opportunity Search
Tips for Effective Listing
Proposed “New” State Page

Setting up a Program
WIOA Apprenticeship Support Strategies
Apprenticeship in Arizona(as of 03/22/16)
Registered Apprenticeship
CONTACT INFORMATION:
Collaborating with PA’S: Recruitment, Roles, & Relationships
History of PA’s
Slide Number 5
PA Supply Projections
Slide Number 10
RETIREMENT/ATTRITION/MORTALITY OF PAS
PA Practice Characteristics
PA Prescribing
ISSUE: Impending Physician Shortage
Slide Number 22
PA Supervision/Collaboration --Types
Slide Number 30
Population – Low Income
Contiguous Areas
Recruitment & Retention Tools and Trainings
STAR² Center
Incentives for Provider Recruitment and Retention
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For more informationArizona State Loan Repayment Programshttp://www.azdhs.gov/hsd/az_loan_repayment.htm.
Bureau of clinicianrecruitment and service
BCRS chart
NHSC Field Strength - National Data
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Funding Tier Refactoring
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For more informationArizona J1 Visa Waiver Programhttp://www.azdhs.gov/hsd/workforce/j-1-waiver/index.htmArizona National Interest Waiver Programhttp://www.azdhs.gov/hsd/workforce/national-interest-waiver.htm
Slide Number 55
North Country HealthCare Family Medicine Residency Presentation to the 2016 Recruitment and Retention Conference 03 31 16
North Country HealthCare/ NAHEC Family Medicine Residency Program
Presentation Overview
North Country Services
Arizona Physician Supply
Undergraduate Medical Education
Allopathic FM Residencies and Graduates per Year
Osteopathic FM Residencies and Graduates per Year
Distribution of Primary Care Physicians in Arizona, 2010
Distribution of Obstetrics and Gynecology Physicians in Arizona, 2010
Rural Arizonans compared to Urban Arizonans
Distribution of Family Medicine Physicians
GME 101
Mission of the Residency
Goals of the Residency
CONTACT INFORMATION

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